Análisis de Sensibilidad

Depressive disorders are often chronic and management may be a long-term process involving several stages (see Table C3.1). The immediate phase of treatment is discussed in Section C2. This section discusses the acute phase of treatment for young people who are not at immediate risk of suicidal behaviour. Continuing management is discussed in Section C4.

Table C3.1 Stages of the management plan

Stage Aims

Immediate phase Comprehensive mental health assessment to clarify diagnosis and specific screening for risk of suicide or self‐harm to ensure immediate safety (see Sections C2.2–2.4)

Acute phase Strengthen therapeutic relationship (see Section C1.1)

Achieve response and recovery — first a reduction in depressive symptoms, then an absence of significant symptoms for a defined period of time (remission)

Monitor risk and progress Minimise impairment

Continuation and maintenance

(see Section C4)

Consolidate response and avoid relapse Build relapse prevention skills and supports

Monitor progress of young people who have had more severe episodes Prevent recurrence

Throughout management, it is important to:

• keep building the therapeutic relationship — in particular ensure that services are welcoming (see Section C1.1), adopt an honest, empathic and non-judgemental approach (see Section C1.2) and discuss confidentiality (see Section C1.3);

• continue taking a person-centred approach that considers the physical, mental, social, spiritual and cultural aspects of each young person and his or her community (see Section C1.1.2); and

• depending on the young person’s age, wishes and circumstances, involve the young person’s parents/carers in discussions about the management plan and treatments (see Section C1.4).

During their treatment, young people will be primarily interested in addressing their own goals and improving their quality of life. This key point can undermine the therapeutic relationship and the young person’s engagement and adherence to therapeutic tasks. For example, a same-sex attracted youth deciding when to disclose his or her

Good practice points

9 Health professionals should provide a good standard of care at all times including maintaining the therapeutic relationship, discussing symptoms and problems, continuing contact, and encouraging a collaborative approach.

10 Health professionals, young people and parents/carers must be aware of the dangers of not treating episodes of moderate to severe depression. Depression is the major risk factor for suicide.

11 Development of the management plan should be person-centred, involving consideration of physical, mental, family, social, spiritual and cultural factors relevant to the young person.

C3.1.1 Initial approaches

For depressive symptoms and mild depression, appropriate initial actions are likely to include continuing care and psychoeducation (information provision and guided self-help, including online interventions or non-directive support). These approaches are also appropriate in managing major depressive disorder, in combination with psychological and/or pharmacological treatments, and are described briefly in Table C3.2. Appendix 6 lists further resources for health professionals and sources of consumer support.

Table C3.2 Initial approaches for managing depressive symptoms Information and

guided self-help

Giving information about depression, the particular type of depression, what causes it and what can help, may assist young people in gaining a sense of coping and competency, and reduce distress and helplessness. It also aids the therapeutic relationship. There are many resources that have been specifically designed for young people, for example: • beyondblue youth fact sheets available from the website below or beyondblue info line

on 1300 22 4636

• websites: Youthbeyondblue (www.youthbeyondblue.com), Reach Out, headspace • online interventions: moodGYM, e-couch

Non-directive support

• Active listening (NHMRC 2004): — asking open-ended questions;

— attending to verbal and non-verbal cues;

— clarifying the information provided by the young person; and — clarifying his or her understanding of the information provided • Person-centred discussion

• Empathy

Lifestyle advice There is good evidence that relaxation, physical activity (see below), and healthy sleep patterns promote feelings of wellbeing. Appendix 6 lists Australian guidelines on lifestyle issues. Lifestyle advice for the general population will need to be adapted to suit the young person’s particular circumstances.

Other non-clinical approaches

There is a lack of evidence to support the use of other physical or psychosocial approaches:

• while many individuals note that their sense of wellbeing is enhanced by physical activity, based on current evidence, physical activity cannot be recommended as an effective treatment for depression in young people (Larun et al 2006 [Cochrane Review]);

• physical or psychosocial approaches (e.g. yoga, massage) and/or complementary therapies (e.g. St John’s Wort [Hypericum perfolatum],4 _{S-adenosylmethionine, vitamins, omega-3 fatty acids) are being explored — the evidence}

for these is limited and generally of poor quality, although many are areas of continuing research (Jorm et al 2006).

C3.1.2 Decision-making about treatments

Current evidence (as summarised in Sections C3.2.1 and C3.3.1) indicates that psychological therapy (specifically CBT and IPT) and pharmacological treatment (specifically fluoxetine) are both effective in treating major depressive disorder in young people.

Unless symptoms are severe, CBT or IPT should be first-line treatment for all young people with major depressive disorder.

When considering treatment options, health professionals need to be aware that a depressive episode may be the first episode of a bipolar disorder, especially if there is a family history of mania.

Table C3.3 provides a summary of responses to a range of diagnoses. However, these are intended as a guide only and increased presenting complexity, such as comorbidity, may require additional actions.

Table C3.3 Key actions in response to diagnosis

Diagnosis Key actions By whom

Dysthymia or mild major depressive disorder

Careful monitoring Non-directive support or group CBT/IPT

Guided self-help (including lifestyle advice, information provision)

School or community-based care (GPs, paediatricians, mental health professionals) +/- specialist support Mild to moderate major

depressive disorder

Psychological therapy (CBT/IPT) if available Guided self-help (including lifestyle advice, information provision)

Community-based care +/- mental health service Moderate to severe major

depressive disorder

Psychological therapy (CBT/IPT) if available + fluoxetine if necessary

Community-based care + mental health service +/– psychiatrist

Severe major depressive disorder

Psychological therapy (CBT/IPT) if available + fluoxetine to reduce symptoms in short term

Psychiatrist

Specialist mental health services Depression unresponsive

to treatment/recurrent depression

Intensive psychological intervention + fluoxetine if necessary

Psychiatrist

Specialist mental health services Depressed phase bipolar Refer to or consult a specialist in the field for

individual advice

Psychiatrist

Specialist mental health services Psychotic depression Urgent referral to specialist services

Consider a more intensive treatment setting Re-evaluation — bipolar

Psychiatrist

Specialist mental health services

In general, effective treatment programs can only be devised on the basis of careful ongoing assessment of the nature of the processes underlying the individual young person’s problems. Treatments should be selected on the basis of: • the known benefits and adverse effects of different treatment options (see Sections C3.2–3.4);

• clinical judgement about the most practical and suitable methods, formats and timing of treatments for that individual;

• consideration of the particular needs (e.g. sociocultural and linguistic background), problems (e.g. negative life events, multiple adversities), resources and preferences of the young person and his or her parents or carers; and • the potential requirement for multiple treatments delivered by different health professionals to treat young people

with co-occurring conditions or concurrent symptoms along with the depression.

When considering CBT/IPT or medication, the young person, and parents/carers should be given an outline of: • the specific treatment modality;

• treatment strengths;

• initial effects (e.g. the potential for focus on symptoms in the early stages of CBT/IPT to increase negative feelings, or for symptoms to worsen in the initial stage of SSRI treatment);

• possible adverse effects and risks; • likely length of time for effect; and

• elements that are central to treatment success (e.g. sufficient practice of CBT/IPT tasks or adherence to medication).

This discussion aims to ensure that the young person and parents/carers have a clear understanding of the proposed treatment and provides the basis for informed consent.

Good practice points

12 Treatment decisions should be based on the findings of assessments, taking into account the severity of symptoms, response to any previous treatments and co-occurring conditions, as well as the young person’s circumstances, preferences and resources.

13 A multidisciplinary team approach is likely to have advantages for individuals with complex presentations.

14 The length of treatment required for effective remission varies. Depressive conditions might require up to 36 weeks of active treatment.