Building stronger future generations: Can we prevent the onset of depression in adolescence?
“Adolescence is like having only enough light to see the step directly in front of you” The Girl Who Chased the Moon, Sarah Addison Allen).
This is an enlightening definition of adolescence — the period in life when everything seems different and when many adolescents are finding their feet. Many see it as a time in life when you start making decisions without thinking too much about it, although this isn’t necessarily always the case.
I still remember that age, I was feeling so curious and eager to behave like an adult, but at the same time I was also so uncertain about my future (even if I was pretending not to care about it).
I was an adolescent just like all of you were, or are, or will be: both fearful and fearless at the same time.
Adolescence represents the transition between childhood and adulthood in terms of psychology, neurodevelopment, interpersonal relationships and behaviour. During this stage, teenagers find themselves facing several exciting, brand-new situations, and everything smells like fresh air. They crave growing up and becoming an adult, sometimes rushing into things as ‘a grown-up’ but then often regretting these rash decisions a few years later.
Nowadays, the massive rise in use of social networks has highly influenced the impact of often bad decisions in teen lives. For example, when I was an adolescent, the only people pressing me to do somewhat stupid things were my closest friends from school; today, facebook, twitter, telegram and Instagram (just to mention the more popular) create a huge group of online “friends” influencing you to do things.
However, all that glitters is not gold: adolescence is all but smooth sailing since it is a critical time for the onset and development of psychiatric disorders, such as depression and bipolar disorder. For instance, depression is the leading cause of disability amongst adolescents, and it has been estimated that about a fifth of adolescents worldwide experience at least one depressive episode.
Furthermore, depression is the number one cause of suicide among teenagers. Sadly, suicide is a global plague among adolescents: a recent study in U.S colleges showed that one out of five students reported experiencing suicidal thoughts, 9% of them had made a suicide attempt and a further 20% reported injuring themself. Concerningly high statistics.
This scenario is worsened by difficulties when diagnosing the disorder. Adolescents are often reluctant to seek help and the reason behind this can vary considerably: there is a lack of perceived need for help and often the perception that self-management is preferable. Moreover, lack of service availability within a reasonable time, a lack of information, and structural factors (such as distance or money) have been identified as the key barriers preventing adolescents from seeking help. However, several countries are now trying to enagage teenagers into mental health, for example creating hotlines, websites and chats where it is possible to talk with peers as well as adults and psychologists (for example, the Samaritans website in UK).
These first-aid solutions are surely a good way to break down the barriers for seeking for help.
Given the fact that depression is a real danger for adolescents, how should we deal with it?
A stereotypical answer can be seen from this quote by Earl Wilson: “Snow and adolescence are the only problems that disappear if you ignore them long enough”.
So what? Do we just let adolescents be adolescents and not care about their problems on the assumption that they will be gone by the time they reach adulthood?
Nothing could be more wrong than this simplistic approach.
Depression, as well as the other mental disorders, do not disappear simply by waving Harry Potter’s wand — they are a real threat and they must be taken into account unless the intention is to build a new generation of young adults incapable of facing real life. So, forget Wilson’s hypothesis.
A more concrete approach is to deal with the harsh reality and take on the beast: teenagers can suffer from depression, and depression is a threat to teenagers. However, depression can be successfully defeated by using non-pharmacological approaches, such as psychotherapy. Although, sometimes defeating the monster is not easy, and in more severe cases, pharmacological interventions with antidepressants, under experienced care of a child and adolescents psychiatrists, can be a solution.
An informed decision made jointly by the psychiatrist, care givers and the adolescent, and one not ever taken lightly.
But what about a prompt intervention before the onset of the disorders and not once symptoms are already present?
Prevention means understanding those who can be categorised as at ‘high-risk’ of developing depression and implementing appropriate strategies to prevent the start of the disorder.
For example, it has been shown that increased levels of inflammation — the body’s defence response which protects us against threats such as infections and injuries — might represent a risk for developing depression. For this reason, clinical trials might aim to treat depressed patients with anti-inflammatory drugs in order to cure depression and reduce the risk for the disorder.
To prevent also means to untangle the underpinning mechanisms, the causes behind depression, as well as the recognising the early signs for the identification of depression in early life.
In the few last decades, several steps have been taken to identify the causes underlying adolescent depression, as well as to identify new and successful preventative strategies to tackle the risk of mental health problems in younger generations.
During recent years, numerous programs have been developed for mental health safety, offering concrete help and support to children and adolescents who have difficulties with their emotional or behavioural wellbeing.
For example, in the UK, CAMHS (Child and Adolescent Mental Health Services) has been established, whereas in Italy, where I live, several hospitals have established similar projects for 15 to 24 years-olds, such as the ones at Milan Niguarda and Padua Hospitals.
However, it is important to note that adolescents from high income countries represent the lucky ones who can benefit from such associations, whereas those from middle to low-income countries are definitely not so blessed, for several (and I will say, crystal-clear) reasons.
And then we had an ‘IDEA’…
In this context, it is noteworthy to mention the IDEA project (Identifying Depression Early in Adolescence) -in which I am actively involved as it is my PhD project — funded by MQ Transforming Mental Health Through Reseach and led by Dr Valeria Mondelli from King’s College London and Dr Christian Kieling from the Universidade Federal do Rio Grande Do Sul (Brazil).
The project aims to understand the cultural, social, genetic, and environmental factors leading to the development of depression in adolescence. This project seeks to identify risk factors in middle and low-income countries, focusing now on Brazil, Nepal, and Nigeria.
By identifying the biological and cultural risk factors, researchers aim to possibly recognise adolescents at high or low risk of depression in advance, with the aim of immediately acting and implementing preventive strategies.
The project is also involved in understanding the feasibility of using these strategies in low-income countries such as Nigeria and Nepal, as well as the possibility of developing a wider screening strategy for thousands of adolescents. For example, blood and saliva tests might be employed in schools and villages to theoretically divide adolescents into groups and try to prevent the onset of the disorder in those teenagers classified as most likely to develop depression at some point during their lives.
Albeit the noble intention of such programs and ideas, much more is needed to be done, especially to explain the importance of preventing mental disorders and to act right away.
Although early on, data from the IDEA project are starting to suggest how some adolescents feel worried about confiding in someone about their emotions, as well as feeling scared about a likely diagnosis of depression. Moreover, just to be classified as a “high risk” individual may cause some level of anxiety for some, as the possibility of becoming depressed represents a permanent black mark.
The reason I say this is because of the undeniable stigma that often goes hand-in-hand with mental disorders, and which persists worldwide despite the effort of psychiatrists, psychologists, researchers and associations which desperately try to revert this unhealthy trend.
We need to emphasise information about mental health, the symptoms, the therapies and the importance of seeking help when necessary, especially to younger generations.
Adolescents should be taught that certain symptoms must be taken into account because they might be the first clue of a deeper disorder and that when identified early, such progress can be halted.
Furthermore, we should also train educators and parents to recognize the early signs and how to successfully mediate the sometimes-tough relationship between adolescents and mental health experts.
It is essential to tell adolescents that they are not alone and will be supported: depression is not a conviction and it is not their fault.
On a more scientific level, a question arises: what is missing in this prevention machine?
The answer is as much foreseeable as it is complex: a biomarker — that is a biological and measurable indicator of the risk for developing depression or the current presence of the disorder.
To date, researchers have found neither a suitable panel of biomarkers able to classify youngsters at the risk of developing depression, nor indicators of its presence.
The IDEA project also aims to identify such biomarkers to better distinguish depressed, low and high-risk adolescents, for starting successful prevention strategies, both pharmacological or not. For example, a well-characterized panel of biological markers can be the key point for a wide-spread screening strategy for adolescents — and especially in poorer countries where the majority struggle to obtain an adequate treatment for mental disorders.
Given the difficulties in accessing basic treatments in these nations, overdiagnosis and overtreatment (always pinpointed by experts as drawbacks of screening programs) seem a remote and avoidable possibility. Moreover, please be careful in considering that screening adolescents does not mean to put a label on them, instead increasing their awareness and encouraging new ways to ameliorate monitoring strategies in schools as well as at home.
In conclusion, to predict and prevent the development of adolescent depression is the first step for reducing the burden of the disorder, starting by eliminating its intrinsic stigma. To pay attention to adolescents’ health is the first step to make a real difference in their mental wellbeing.
We can all make a difference, we can all contribute to ameliorating the quality of life of children and adolescents worldwide. Let’s start now!