Depression in adolescence is not rare. The last major survey (Green et al, 2005) reported that 80,000 children and young people in UK were suffering from depression: 0.2 per cent of under-10s are depressed; 1.4 per cent of 11 to 16-year-olds are depressed at any one time.
When it comes to mental health and wellbeing, our best estimates suggest that between 10 and 20 per cent of teenagers will suffer from depression at some point in adolescence – and this will not be a fleeting attack of “the blues”, but persistent, pervasive low mood.
Even this figure may be an underestimate: teenage depression is often not recognised either by family or schools, nor reported by the young. And factors that may raise depression rates in the young (such as climate change and latterly Covid-19 and its fallout) have come to considerably more prominence in 2020 than was the case in 2005.
Depression is a serious matter. It is a wretched experience for the sufferer. And even at milder levels, depression can disrupt social relationships, damage academic performance (Fröjd et al, 2008). Moderate depression can make a teenager feel suicidal (AAP, 2000).
Anxiety and depression: A five-part series by Dr Stephanie Thornton
Part 1: Anxiety and depression: The new normal? March 2020: https://bit.ly/2wE3Bye
Part 2: Anxiety and depression: Are they co-morbid? April 2020: https://bit.ly/3blzR7u
Part 3: Anxiety and depression: When should we intervene: May 2020: https://bit.ly/2T0KlTr
Part 4: Anxiety and depression: Managing anxiety in the classroom: June 2020: https://bit.ly/2XJXiUu
Part 5: Anxiety and depression: Managing depression in the classroom: July 2020: https://bit.ly/2YJ9DJ0
Advances in neuroscience have shown that depression can create neurological change (Miguel-Hidalgo & Rajkowska, 2002; Steinberg et al 2006). Left unresolved, adolescent depression can easily set the scene for a lifelong tendency to mental health problems (Harrington, 2001).
Finding ways to support depressed teenagers is obviously important. Schools are On the front-line: teachers are better placed than any except parents to notice warning signs – and better trained than most parents to recognise those warning signs for what they are.
Alas, CAMHS is so poorly resourced that few depressed teenagers will ever be seen, and those who are may wait for a very long time: only those who have made genuine suicide attempts are likely to get any sort of priority (SecEd, 2018).
Teachers are on the front-line, not only to recognise, but to support adolescents suffering depression. Expert advice is that when teachers recognise teenage depression and intervene supportively, many of the miseries and harms associated with depression can be mitigated (Crundwell & Killu, 2010).
Recognising when a teenager is depressed
Teenagers may be reluctant to reveal the emotions associated with depression: sadness, low self-esteem, self-blame, feelings of hopelessness and helplessness.
So behavioural changes are the teacher’s first cue that an individual may be depressed: concentration falters, academic performance falls off; there is likely to be loss of interest in usual activities and social withdrawal. Such changes in behaviour need investigating: can you offer a safe, confidential place where the individual will feel confident and trusting enough to discuss the emotions they may be experiencing, and why.
Sensitivity, allowing the teenager to reveal themselves at their own pace and not through pressure is vital, as is a non-judgemental approach, whatever may be said. Such discussions may confirm a suspicion of depression, and may also allow some assessment of the cause and severity of the problem. But even a teenager who refuses to discuss the matter may still benefit from knowing that the option is there and that they are being thought-about by staff.
Identifying appropriate levels of intervention
Very serious, “major” depression such as that associated, for example, with bipolar disorder needs urgent professional intervention. Get the family, and the student’s GP involved asap. This level of depression gives the highest risk for both long-term damage and suicide, and may impact very obviously on everyday life.
Having said that, it is worth noting that recognising major depression is sometimes easy, but sometimes not: even professional screening methods are not always 100 per cent reliable.
Teachers are not trained to make subtle distinctions in triaging the borders of major depression, and it is unfair that we are expected to do so. The best you can do is trust instinct. If you fear that a student may have a major depression, seek advice, perhaps from the school nurse or educational psychologist, and share the decision.
Major depression needs professional intervention. Lesser levels of depression still need real support, and are unlikely to get it from CAHMS, but there are things one can do in school. This is especially true where a student has confided their feelings, but is also true where behaviour raises the suspicion, but the student won’t confide.
A safe place to talk
Offering a safe place to talk, not just in initially identifying depression, but in providing on-going support may give a crucial life-line to many depressed teenagers. These individuals often feel alone, trapped with their problems. Just having someone who they know will listen sympathetically, kindly, and without judging can make an enormous difference, even if it takes time for some individuals to take advantage of that.
The teacher’s temptation in such discussions is to try to fix the student’s problems. Sometimes, that may be appropriate and practical: where the depression has been triggered by academic struggles, for example, or by some other specific situation, it may be possible to work out, with the student, some way to deal with the issue (extra tuition, for example, or addressing a bullying issue).
But often, no simple practical solution is possible. It is never helpful to pretend otherwise, or to downplay a teenager’s feelings. But even when you cannot fix the problem, such conversations offer a real context for supporting the depressed individual. The main gift you can give, in such discussions, is listening well. Simply sharing the problem, being heard, feeling understood can relieve the burden of feeling hopelessly alone.
Intervention?
A practical classroom intervention may be easier than we think. We assume that depression requires drug treatment and/or psychological interventions such as counselling. However, research suggests that neither of these are as much use as we hoped (Thapar et al, 2012).
The most effective intervention is CBT (cognitive behavioural therapy), and school-based CBT programmes delivered by trained professionals have been shown to be beneficial in addressing depression (Calear & Christensen, 2010). But resources for such programmes are vanishingly scarce.
However: the premise of CBT is that depression is fuelled by a negative mindset – in other words by an “attention bias” that focuses on the negative and overlooks the positive. CBT aims to alter this attention bias. A new wave of research into “attention bias modification training” (ABMT) is beginning to report that other interventions, much less demanding of resources than CBT, can have as good an effect, and expert opinion is increasingly that activities that counter a negative attention bias may be the best way to support the depressed in schools.
ABMT in the classroom
ABMT interventions can be very simple. For example: given a display of faces frowning, only one smiling, how fast can you find the smiler? The negative attention bias of the depressed makes them measurably slower at this than others.
However, with practice, they improve. Remarkably, the research suggests that even simple tasks like this can create a more positive attention bias, and that this more positive mindset extends well beyond the task itself: practice with such tasks reduces depression in general (Bechor et al, 2014; Waters et al 2013).
The “find the smiley face” task is available as an app, it may well be useful to point the depressed teenager towards that. And there are other practical ways of modifying a negative attention bias in the classroom.
Counting blessings is an ancient way of countering the negative, and it works at different levels: counting large blessings (I go to a great school/have a loving family, and so forth) is good, but is far less effective than counting small daily blessings (this peach is so tasty, that discussion was so interesting, the wind felt so great on my skin, etc).
At first, the negative attention bias of the depressed generally makes it hard, if not impossible to notice those small blessings of everyday life. But being required to monitor life in order to report those small blessing every day pushes attention toward the positive. Simply asking a class to end the day by writing out or even sharing “five small blessings from today” may alter attention bias in ways that materially benefit the depressive.
- Dr Stephanie Thornton is a chartered psychologist and former lecturer in psychology and child development. To read Dr Thornton’s previous articles in SecEd, including in this series, go to http://bit.ly/2o1BVxK
Further information & resources
- American Academy of Pediatrics: Suicide and suicide attempts in adolescents, Pediatrics 105, Committee on Adolescence, 2000.
- Bechor et al: Attention bias modification treatment for children with anxiety disorders who do not respond to Cognitive Behavioural Therapy, Journal of Anxiety Disorders 28, 2014: http://bit.ly/2ONWA3M
- Calear et al: Systematic review of school-based prevention and early intervention programs for depression, Journal of Adolescence 33, 2010: http://bit.ly/2Szy0EN
- Crundwell & Killu: Responding to a student’s depression, Educational Leadership 68 , 2010: http://bit.ly/39ktals
- Fröjd et al: Depression and school performance in middle adolescent boys and girls, Journal of Adolescence 31, 2008.
- Green et al: Mental health of children and young people in Great Britain 2004, Palgrave, 2005.
- Harrington: Depression, suicide and deliberate self-harm in adolescence, British Medical Bulletin 57, 2001: http://bit.ly/2OLCXsU
- Miguel-Hidalgo & Rajkowska: Morphological brain changes in depression: Can antidepressants reverse them? CNS Drugs 16, 2002.
- SecEd: A quarter of CAMHS referrals are rejected, October 2018: http://bit.ly/2YnDHs2
- Steinberg et al: The study of developmental psychopathology in adolescence: integrating affective neuroscience with the study of context, 2006 (in Developmental Psychopathology 2, Cicchetti et al).
- Thapar et al : Depression in adolescence, Lancet 379, 2012: http://bit.ly/3bpT49v
- Waters et al: Attention training towards positive stimuli in clinically anxious children Developmental Cognitive Neuroscience 4, 2013: http://bit.ly/2UGwJ1m