Opportunities and Challenges in Treating Adolescents and Young Adults With Major Depressive Disorder
Half of all mental health disorders occur by age 14. Early interventions may mitigate progression to more serious and persistent mental health concerns.
Table 1
Table 2
With each national tragedy that involves a young person with symptoms of a mental health disorder, there is a call for increased access to mental health care for all youths. It is estimated that only 25% of children and adolescents who need treatment for depression receive it.1 There are incredible opportunities to intervene and change the trajectory of young people’s physical and mental health as well as their social well-being.
The youths discussed in this article span 2 developmental stages: adolescence and young adulthood. Youths aged 12 through 18 years make up the adolescent population; young adults aged 18 through 24 years, the ages of many college students, make up another developmental group with distinct mental health needs. According to the Substance Abuse and Mental Health Services Administration, 8.5% of adolescents experience a major depressive episode. Nearly half of the adolescents who have major depression (48.3%) report that it severely impairs their ability to function in at least 1 of 4 major areas of their everyday lives (home life, school/work, family relationships, social life).2,3
The prevalence of MDD in college-age youths is thought to be 8.7%, which is higher than in any other adult age-group.2,3 Depression in young adults is associated with an increased risk of substance abuse, unemployment, early pregnancy, and educational underachievement. Suicide, the most serious risk of depression, is the third leading cause of death in 14- to 24-year-olds and the second leading cause of death among college students.4
According to the Institute of Medicine, the onset of half of all mental health disorders is by age 14.5 Early interventions may mitigate the progression to more serious and persistent mental health concerns. Depression responds well to early intervention and treatment, and findings indicate that early treatment significantly decreases the number and severity of recurrent depressive episodes, which have a reoccurrence rate of approximately 60% to 70%.6
The 2009 report, Adolescent Health Services: Missing Opportunities, from the Institute of Medicine and National Research Council, states:
Adolescence is a period when patterns of health promoting or health damaging behaviors are established that will have a substantial influence on health status during adulthood, affecting rates of acute and chronic disease and life expectancy. Identification and treatment of the acute effects of health damaging behaviors provides an opportunity to counsel and educate adolescents about the lifelong benefits of establishing a healthy lifestyle.5(pxii)
Evidence-based interventions for depressed youths
Because adolescents and young adults are typically healthy and do not routinely have much contact with mental health care providers, primary care physicians are encouraged to follow the US Preventive Services Task Force Recommendation to screen adolescents and young adults for depression.7 Many young people do not know that their irritability, anger, sadness, and feelings of gloom may be symptoms of a treatable medical illness. Education about depression as a treatable illness with symptoms that respond to active treatment should be presented in academic programs at all levels.
Findings from studies indicate that there are very effective treatments for depression in youths, including cognitive-behavioral therapy (CBT), interpersonal psychotherapy, and antidepressant medication.8 CBT may provide protective factors for suicide and, in combination with an SSRI, provides the fastest- and longest-acting therapeutic effects.9,10 Psychiatric guidelines recommend that for optimal patient outcomes, psychotherapy and medication management (when indicated) need to occur simultaneously.11,12
Recent research, including systematic reviews and meta-analyses, supports CBT as an effective first-line treatment of depression in youths and also as an effective adjunct to medication in the treatment of MDD.13-16 Although CBT is well established as an effective treatment of depression, affected youths do not routinely receive it because of the shortage of mental health clinicians. To increase access to evidence-based CBT, the Creating Opportunities for Personal Empowerment (COPE) program was created. This is a 7-session manualized intervention based on CBT that can be delivered by a variety of trained health care clinicians and teachers.
What new information does this article provide?
At every visit with adolescents and young adults, there is an opportunity to intervene and change the trajectory of young people’s physical and mental health by promoting healthy lifestyle behaviors and healthy decision making, providing guidance about health-damaging and risky behaviors, and presenting coping skills using an evidence-based cognitive-behavioral approach.
What are the implications for psychiatric practice?
A cognitive-behavioral skills-building program such as COPE can augment medication management and provide effective evidence-based treatment for adolescents and young adults with MDD.
COPE for teens and young adults
The COPE program can be incorporated into 30-minute counseling sessions or 20- to 30-minute medication management visits. We find that by using this portable manualized program (with skill-building activities for practice at home), we can ensure that young people are taught needed cognitive-behavioral and coping skills (see Table 1 for more information about COPE). Although there are other excellent manualized CBT-based programs for adolescents, such as the Adolescent Coping With Depression Course,17 we use COPE because it is easily adapted for brief visits and short courses of therapy. In addition, it is structured and easily understood by teens and young adults, and it is user-friendly.
A meta-analysis by McCarty and Weisz13 identified 12 components found in effective therapy for depressed adolescents, including measurable goals/competency, adolescent psychoeducation, self-monitoring, relationship skills/social interaction, communication training, cognitive restructuring, problem solving, behavioral activation, relaxation, emotional regulation, parent psychoeducation, and the parent-child relationship. All of these components are included in the COPE for teens manual (Table 2).
The COPE program is delivered by clinicians using a 7-session manual that incorporates basic CBT principles with developmentally appropriate and engaging examples and illustrations; it teaches coping strategies with skills-building activities (ie, practice and homework).18 When piloted in a community mental health center with teens referred for psychiatric care (n = 15), measured outcomes pre- and post-COPE (Beck Youth Depression and Anxiety Inventories) showed that this CBT-based intervention decreased depression and anxiety in teens and improved self-concept.19 This confirms our experience of clinical improvement-decreased depressive symptoms. In their program evaluations, our patients have reported that even in the brief, 20- to 30-minute visits, there is time to bring up concerns and review medication response in addition to covering COPE session content.
Because the program is limited to 7 sessions, more youths can participate in the program in busy practice settings, where demand for clinician time is great. COPE can also be delivered in group format, for which similar positive outcomes have been seen.18 A significant decrease in depression and anxiety scores was seen from pre-intervention to post-intervention, and from pre-intervention to 4-week follow-up. Adolescents reported increased positive feelings about managing negative emotions. Evaluations completed by participants indicated that the COPE intervention was a positive experience.
A 15-session COPE Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, and Nutrition) program, which includes the cognitive-behavioral skills-building sessions in the 7-session program, is available to promote the mental health and healthy lifestyle behaviors in high school adolescents.20 Findings from a recent trial (N = 779) revealed that teens who received COPE had fewer depressive symptoms, better social skills and academic performance, healthier behaviors, and less alcohol use, and were less overweight and obese than those who received an attention control program.21 A college-age version of the program-available online as a 3-credit course-has also shown promising outcomes, including decreases in depression/anxiety and increases in healthy lifestyle behaviors and retention.22
In a study to assess the preliminary effects of an academic course based on the COPE 15-session program, Freshman 5 to Thrive/COPE Healthy Lifestyles, the COPE group reported greater intentions to live a healthy lifestyle than did the group who took an academic success course.22 Students in the COPE group also significantly increased their physical activity from baseline to post-intervention. Students with elevated levels of anxiety and depression in the COPE group at the start of the study had normal levels of these symptoms post-intervention.
Challenges and opportunities
Adolescents. Adolescence is a period of both risk and opportunity. We know that the young person’s brain undergoes massive reorganization between ages 12 and 25. Neurodevelopment and neuroplasticity in the adolescent make for some incredible strengths, including increasingly faster thinking, but the gradual progression toward maturity also accounts for the lags in problem solving, emotional regulation, and appreciation for cause and effect. Adolescents may take risks that can jeopardize their health during these years as well as contribute to the leading causes of death and disease in adulthood. During adolescence, a range of health conditions can be identified and addressed in ways that affect not only adolescents’ functioning and opportunities but also the quality of their adult lives. Adolescence provides many opportunities to develop habits that create a strong foundation for healthy lifestyles and behavior over the full life span.5
Adolescents experience the intensity of their emotions while forming connections with others and learning to make their own decisions. The young person who has depression is especially vulnerable to falling behind in school and, without the energy for participation in social or school activities, he or she can lose out on growth/mastery activities. If teens are sad, depressed, and/or irritable, they do not form the supportive relationships they need with family, peers, and teachers.
Teens are dependent on families to get them to treatment. Adolescents are often on long waiting lists for treatment, and the majority of visits to mental health care clinicians are for medication management, which may or may not include CBT. Stigma, cost, time, and location of clinics are common barriers to teens’ treatment. Parents have work obligations and responsibility for other siblings and are concerned about stigma, bureaucracy, finances, more financial forms to complete, and an unfamiliar system to navigate.
Schools are an ideal environment in which to implement early intervention programs. The goal is for every young person to know that depression is a treatable medical condition and to be aware of the symptoms, including irritability and anger. A depressed adolescent needs to be able to tell a trusted adult about how he is feeling and to seek immediate or early treatment.
School-based programs are uniquely positioned to mitigate the impact of early stress, modulate stress reactivity, and promote self-regulatory functions and effective coping. This represents a life course approach to the relationships between life experience and neuromaturation. Neuroplasticity helps individuals adapt to both positive and negative environments with enduring outcomes for health, development, and opportunity across the life span. Through health promotion and early intervention, we can boost adolescents’ potential for success exponentially.
Young adults. Students present to college health centers seeking help for crises and challenging periods, such as a difficult course load or a romantic break up. The diagnosable mental disorders that students present with are primarily depression and anxiety, which are often comorbid. Among persons with depressive symptoms, young adults report significantly lower rates of counseling use.23 Despite the developmentally related stressors, the use of mental health services is relatively low. Some explanations for this include:
• Older adolescents and young adults are generally healthy and are not routinely seeing health care professionals
• Their parents’ influence is diminished, and the decision regarding treatment falls to the young adult
• Young adults often lack knowledge about symptoms, and they do not recognize their difficulties as related to diagnosable mental disorders
In the National Longitudinal Study of Adolescent Health,23 young adults aged 18 to 25 years with self-reported mental health needs gave some of the following reasons for not seeking care: “I couldn’t pay.” “It is difficult to make appointments.” “I didn’t know who to see.” Tailoring mental health treatment to the specific needs of this young adult population will help engage the young person and promote healthy choices.
A cognitive-based treatment approach is likely best suited to the young adult because it integrates well with his intellectual abilities. For young adults, the emphasis should be on positive decision making, goal setting, problem solving, and dealing with stress in healthy ways. Because of their high level of functioning, many young adults are enrolled in higher education academic settings, starting their careers, or serving in the military.
Whether these youths are on campus, are part of the workforce, or are in basic training, there is a great opportunity to provide education about common mental health disorders, including contributing factors, etiology, symptoms, presentations, and course of illness, and the most effective treatments, including medications. Clinicians can encourage them to engage in healthy behaviors, such as eating a healthy diet and getting enough sleep and exercise, and can provide strategies for stress relief, such as mindfulness. Young adults often express ambivalence about taking medications, expressing concerns about stigma. They like to do their own research and engage in lively discussions about the pros and cons of each treatment option.
In youths with MDD, we incorporate COPE as a routine intervention. If an antidepressant is prescribed, the COPE sessions are incorporated into medication management visits. COPE provides an overview of common stressors young adults face and introduces cognitive-behavioral skills along with coping strategies. This allows the young adult to find the activities and skills that fit best. COPE can be used as both an evidence-based treatment and a preventive intervention for adolescents and young adults at risk for mental health problems.
Implications for practice
For the most comprehensive developmentally based prevention, assessment, and management approach, we recommend screening and cognitive-behavioral skills-building programs for all adolescents and young adults. For example, adolescents and young adults should be screened for depression at every interface with a health care professional and receive a CBT-based program to equip them with the knowledge and skills to deal effectively with the most common stressors they face through the various developmental stages.
Augmenting a 20- to 30-minute medication management appointment with a CTB-based skills-building program provides patients with psychotherapy that not only treats depression but also teaches the skills needed to cope with real-life stresses. Including health promotion information and guidance is also recommended for every visit with these young people so that:
. . . all providers of adolescent care services will make disease prevention, health promotion, and behavioral health-including early identification, management, and monitoring of current or emerging health conditions and risky behavior-a major component of routine health service.1(p10)
We can leverage the neuroplasticity and progressive neurobiological maturation of youths and intervene so that the neurological pathways are healthy and strong. We can create better lives for youths and can give them the tools to be effective, healthy adults by empowering them to use their individual strengths and positive abilities to establish and meet their highest goals and accomplish their biggest, boldest dreams.
Disclosures:
Dr Melnyk is Associate Vice President for Health Promotion and Chief Wellness Officer, Dean and Professor at the College of Nursing, and Professor of Pediatrics and Psychiatry at the College of Medicine of The Ohio State University in Columbus. Dr Lusk is Clinical Associate Professor at the College of Nursing at The Ohio State University in Columbus, and Psychiatric Nurse Practitioner at the Community Health Center of Yavapai County in Prescott, Ariz. Dr Melnyk reports that she has lectured worldwide at universities and health care organizations on evidence-based practice, for which she receive travel expenses and honoraria. She received honoraria for serving as an editor of books on intervention research, evidence-based practice, and worldviews on evidence-based nursing. She is a part-owner of COPEforHOPE, which does training workshops and disseminates the COPE program for hospitals, and of ARCC, LLC, a consulting company that works with health care systems on improving quality of care through evidence-based practice. She is the owner of COPE2THRIVE, a company that disseminates the COPE Healthy Lifestyle and Mental Health programs. Dr Lusk reports no conflicts of interest concerning the subject matter of this article.
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