Down in the dumps
Dr Rob Wrate is unashamedly a man with a mission. The consultant in adolescent psychiatry at the Young People's Unit of Royal Edinburgh Hospital is one of the authors of the newly released report The Recognition of Adolescent Depression in Scottish Schools 1997-2000.
"Clinical depression is one of the most common mental health problems but it's invisible," he says. "We're on a mission to improve recognition rates and to raise awareness of possible treatments which range from counselling and psychotherapy to cognitive therapy and anti-depressants."
A major part of this mission is to enlist the help of secondary school teachers to improve clinical depression recognition rates and, consequently, rates of referral. To this end, the Young People's Unit has produced two video-based teaching packs: a pack for teaching staff development and a pack for pupil development, promoting peer education. It has also set up a series of half-day workshops around Scotland to promote the teaching packs and discuss the findings of the report, which was funded by the Scottish Executive.
Although depression of clinical severity is present in about one in 30 teenagers aged 14 to 16, according to the report, it is commonly unrecognised. Distinct from so-called teenage blues, this depression is more prolonged, more disabling and can have wide-reaching effects. Symptoms include: l a persistent low mood that doesn't lift; l persistent over-sensitivity (which can appear as aggressive outbursts); l isolation from friends and family (hiding away); l difficulty with attention, decision-making and memory; l difficulty in getting off to sleep or disturbed sleep; l loss or gain in appetite and weight; l low self-esteem;
* anhedonia (loss of pleasure in hobbies, work and relationships); l pervasive negative thinking; l excessive guilt or self blame; andl suicidal thoughts.
If some of these symptoms occur for most of the day, for more days than not and if they are causing a significant impairment in functioning, then they could be indicating depression.
"The video packs are structured to help both pupils and teachers to distinguish between clinical depression and teenage blues," says Dr Wrate. "Many young people with depression don't recognise they have it but other people will. Hence the importance of teachers and the adolescent peer group."
He continues: "Secondary schools are the single biggest service provider for young people. On their own, adolescents are poor health consulters, so schools play a very important role in their health and well-being.
"Teachers are already multi-tasking. They are already aware of pupils' health and problems and are embracing widening roles. This is an extension of what they aspire to do anyway."
Dr Wrate alludes to child protection guidelines. "Teachers are the most common professionals confided in regarding abuse and we'd hope this would become true regarding depression. Child sex abuse is much less frequent than clinical depression. Young people themselves often tell a teacher they're being abused. Could they be better able to tell a teacher that they themselves or a friend is suffering from depression? We certainly hope so.
"It took more than 10 years for indicators of abuse to become common knowledge. Let's try to do this for depression in five years."
Teachers are the experts in teenage behaviour; no other group sees as much of it every day, says the Depression in Young People teacher training pack devised by Royal Edinburgh Hospital's Young People's Unit. Teachers are uniquely placed professionals with the ability and opportunity to observe teenagers over a period of time. Their diverse knowledge base, which may include knowing a bit about a young person's siblings, parents and friends, puts them in advance of a psychiatrist or psychologist in a clinic situation, who "will only be able to build up a snapshot view" compared to their "pretty comprehensive picture".
However, teachers are not being asked to be diagnosticians. "It is certainly not part of your job to be diagnosing depression or acting as a therapist," says the teaching pack.
"What you can do is detect youngsters who are showing signs of depression and investigate the situation through discussion with other teachers, the pupil themselves and your guidance system and refer on when appropriate."
Alongside teacher recognition, Dr Wrate and his colleagues are also emphasising the importance of peer recognition.
"Pupils may learn from the video pack, may be able to speak on behalf of each other and of themselves. Peer recognition could play a very important role," says Dr Wrate.
"The aim is to make this part of a rolling programme of community awareness. We need to create a climate in school where clinical depression gets recognised and where young people are part of the process of recognising it. This will help to demistify it."
The role of teachers is, however, doubly important because most adolescents tend not to consult their parents or their GP. "Teachers should encourage this, even though depressed adolescents tend not to do it," says Dr Wrate.
"Where depression gets recognised in school, our research shows that the number who approach GPs or parents is a real minority. But the school health service can pick it up and refer to the psychologist or a psychiatrist.
"Following our study, and in spite of the advice given, only one in six of the young people identified as clinically depressed raised the matter with their parents. You can see why depression isn't recorded or treated."
A larger number of girls and women are treated for depression than boys and men because the latter are commonly low consulters regarding health problems and are not as articulate at putting feelings into words. This is especially true of adolescents. "At the age of 14 or 15, in terms of cognitive language development, boys can be up to two years behind girls," says Dr Wrate.
"They tend to show depression through aggression or irritability."
Dr Wrate gives a case study example of a profoundly depressed 14-year-old boy in S3. "When I interviewed him he did not recognise that he was depressed, nor what depression was. He didn't have the construct.
"He was waking at 4am, was not eating and was losing weight. He couldn't watch TV or the cinema for more than 10 or 15 minutes. He had no concentration in class, couldn't cope academically or socially and was becoming more isolated.
"He was being excluded regularly but didn't have the cognitive development to understand he was depressed.
"He wouldn't talk to a teacher, a GP or his parents. He didn't refuse. He just didn't do it.
"He had no drive, no capacity, and small tasks or problems seemed huge.
"He had not been picked up for depression."
Clinical depression naturally takes its toll on school work and can result in academic failure. Yet, argues Dr Wrate, it is seldom if ever used as grounds for appeal in exams because it goes largely unrecognised.
"How many mental health reports are going into the Scottish Qualifiactions Authority?" he asks. "Whatever the answer, and I suspect there are very few, there should undoubtedly be far more. If a pupil misses a lot of school because of glandular fever, for example, that would be taken into account. Then why not for depression?" As depressed teenagers tend not to seek help they often go unrecognised, untreated and left suffering alone, says the teaching pack, emphasising the importance of teacher recognition. But if a teacher suspects or recognises the condition, how pro-active should he or she be?
"That is the big question," says Dr Wrate. "A lot depends on how well you know the young person. Kids like to be left alone. But depression tends to recur. Most adults with clinical depression had it first in adolescence.
"How far should teachers go? I'm not sure what the answer is, but waiting for the young person to come and tell you is not it.
"The bottom line is that there aren't people who can beat depression on their own any more than they can beat asthma. It's not about will-power. It's about getting outside help from counselling, peer support, guidance, psychological services or specialist support like ours. The longer you leave it the more of this cascade of support you will need."
Referral can lead to counselling, psychotherapy, cognitive therapy and the prescription of anti-depressants. With regard to the last, Dr Wrate argues it is not a case of giving a teenager a course of drugs and leaving them to get on with it. On the other hand, he shows signs of irritability himself at those who dismiss drugs as part of a treatment.
"Eight-year-olds take Ventalin for asthma. But you don't think 'poor dear', heshe has been put on drugs. So there's a lot of sentimental claptrap about drugs.
"If the drugs work, you give them. It's not a cure and it's not the only thing you do, but it can give relief. An anti-depressant can help bring depression to an end in six to eight weeks rather than the person suffering for two years.
"It's not just that one in 30 young people between the ages of 14 and 16 get depression. Somewhere between one in six and one in 10 of those young people will have that depression for two years."
Regional meetings to discuss the findings of The Recognition of Adolescent Depression in Scottish Schools 1997-2000 report and to introduce the two video-based teaching packs will take place on May 31 in Edinburgh for south-east Scotland
June 1 in Glasgow for the west of Scotland and Western Isles
June 7 in Aberdeen for Grampian, Highland and the Northern Isles
June 8 in Perth for Tayside and central Scotland
These meetings are aimed at secondary teachers and support services for schools in Scotland. Senior staff representing specialised mental health services for adolescents will also be present to talk about local services.
Entry is free with registration. Meetings begin at 1.30pm and conclude at 4pm; buffet lunch from 12.30pm. Video teaching packs will be available to order at the meetings.
For fuller venue, registration and video pack information contact Ann Maguire, The Young People's Unit, Royal Edinburgh Hospital, Morningside Place, Edinburgh EH10 5HF, fax 0131 537 6102.
Strategies to help adolescent depression
When setting up the meeting, bear in mind tact and privacy to ensure an atmosphere of confidentiality.
* At the beginning of the meeting, clearly spell out what is and what is not confidential, such as if a teacher believes a pupil to be at significant risk of self-harm, confidentiality would be broken. Clarify the rules on reporting illegal activities.
* Be open and non-judgmental. Use questioning to understand the pupil's perspective and to clarify the problem areas.
* Be aware of time so that the pupil has a chance to get himself or herself together before they have to face friends in the classroom or playground - perhaps organise a place of sanctuary where they can wait until they are ready to leave.
* Round up the session by going over the main points, the action plan you've made together - rather than imposing a solution that the pupil will not feel belongs to them - and spell out a fallback position to serve as a safety net.
* Make notes to record what works best as a guide for future work with that pupil.
(taken from Depression in Young People teacher training pack)