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In assessing depressive symptoms and considering a diagnosis of depression, most health professionals will conduct a clinical interview that checks for the presence of symptoms consistent with diagnostic criteria for depression, in line with major international classification systems for depressive conditions — ICD-10 and DSM-IV-TR (diagnostic criteria for these classification systems are given in Appendix 4). Assessment tools may assist this process and consideration is also given to other physical and mental health conditions that may cause depressive symptoms. If depressive symptoms are identified, it is mandatory to include an assessment of suicidal thinking and behaviour (see Section C2.3).

Table C2.2 Brief characterisation of depressive disorders

Dysthymia Depressed mood or irritability, on most days for most of the day, lasting for at least

1 year, together with two other symptoms such as: • changes in appetite and weight;

• changes in sleep;

• problems with decision-making and concentration; and • low self-esteem, energy and hope.

Major depressive disorder

A depressive episode of at least 2 weeks duration consisting of either sad or irritable mood or anhedonia (loss of the normal pleasure response), together with at least five other symptoms such as:

• social withdrawal; • worthlessness; • guilt;

• suicidal thinking or behaviour; • sleep increase or decrease;

• decreased motivation or concentration; and • increased or decreased appetite.

For a diagnosis of major depressive disorder, these symptoms must cause clinically significant distress or impaired social, occupational or other functioning, represent a change from previous functioning, and must not be attributable to substance use, medication or other psychiatric or medical illness.

Bipolar I disorder History of manic or hypomanic episodes.

Usually also a history of one or more episodes of major depressive disorder.

Bipolar II disorder At least one hypomanic episode and at least one major depressive episode. Depressive episodes are more frequent and more intense than manic episodes.

C2.2.1 Assessment questionnaires, scales and interviews

A wide variety of questionnaires, scales and tools are used to assist the process of diagnosis. These range from standardised structured interviews to self-report rating scales of depressive symptoms. Structured instruments are used in research studies and are highly prescriptive, to the point of giving the exact wording of the questions to be asked. Structured interviews are precise and can be used to estimate the prevalence of various diagnoses and quantify depressive symptoms and adverse effects. However, they are lengthy, may appear overly scripted and formal, and are not practical for widespread use in clinical practice.

Brief screening tools and rating scales are useful as initial measures of generalised distress and depressive symptoms. While they do not provide a diagnosis, they can assist health professionals in decision-making about whether

further assessment is required to exclude depression or another mental health disorder. The tools are either clinical assessment scales (which are measures of symptoms, functioning and disability completed by the health professional) or consumer self-reports (which are measures of problems, symptoms or distress). These tools have been validated in general populations and appear not to be biased with respect to sex and level of education. However, they may not be useful in specific populations (see Cultural considerations below).

Questionnaires that focus specifically on depressive symptoms (e.g. Reynolds Adolescent Depression Scale [RADS]; Center for Epidemiologic Studies Depression Scale [CES-D]; Hospital Anxiety and Depression Scale [HADS]; Children’s Depression Inventory [CDI]; Beck Depression Inventory [BDI]) provide a stronger indicator of depression than more general mental health questionnaires (e.g. Strengths and Difficulties Questionnaire [SDQ]; Kessler Psychological Distress Scale [K6 and K10]; Child Behaviour Checklist [CBCL]).

The SDQ, a general screening measure of mental health symptoms, can be accessed online (http://www.youthinmind. co.uk), scored immediately and feedback provided by youth-friendly graphical display or a technical report.

The main features of a range of validated assessment tools specific to depression are given in Appendix 5. These Guidelines do not advocate any particular questionnaire or measure. A useful principle is for health professionals to decide on and use a limited set of measures, and become expert at their administration and the interpretation of the clinical significance of the test results. This strategy also lends itself to repeating the same measure post-treatment and during follow-up and monitoring phases of care.

Cultural considerations

Accurately assessing depression in Aboriginal and Torres Strait Islander young people or young people from culturally and linguistically diverse backgrounds is complex as cultural issues can misrepresent abilities or states of mental health (Drew 2000).

Several instruments have been translated into a range of languages, including the K10, SDQ and Mini Mental Health Examination. Printable versions of the SDQ in more than 20 languages are available. The Youth Self Report (Achenbach & Rescorla 2001) has been used to assess self-rated problems in many societies (Ivanova et al 2007). The Westerman Aboriginal Symptom Checklist—Youth (WASC-Y) (Westerman 2002; 2003) is a tool for early identification of depression, anxiety, suicidal behaviours and self-esteem problems in Aboriginal young people in the 13 to 17 year age group.

C2.2.2 Assessing the severity of a depressive episode

In assessing the severity of a depressive episode, it is important to examine the frequency, duration and strength of symptoms and their impact on the young person’s functioning (see Table C2.2 and Appendix 4). While the number of symptoms provides an indication of severity, clinical judgement is required — for example, one prominent severe symptom may cause a similar level of impairment to several moderately severe symptoms. In the ICD-10 classification system, along with agitation and suicidal thinking (enumerated below) the individual’s subjective distress, and ideas of worthlessness and guilt are emphasised.

Other considerations in specifying the severity of a depressive episode include: • the level of social disability and functional impairment;

• whether there is suicidal thinking, active plans or intent (see Section C2.3); • the level of agitation;

• evidence of self-neglect;

• past history of depressive episodes and response to any previous treatments; • number of ‘somatic’ symptoms;

• mental health problems in the family; and • history of manic episodes.

Standardised depression inventories generally have normative data that may also be useful in determining the severity of depression.

Good practice point

7 A diagnosis of major depressive disorder is based on clinical judgement, including consideration of the young person’s level of impairment and whether symptoms are consistent with accepted diagnostic criteria (DSM-IV- TR; ICD-10).

C2.2.3 Excluding other causes for depressive symptoms

Assessing and diagnosing depressive disorders in young people can be complex, particularly where depression is part of a broader constellation of physical and/or other mental health problems. Although variously defined, differential diagnoses are plausible alternatives; that is, a list of diagnoses that may fit the presenting symptoms.

Physical health conditions

Mental health symptoms, including depression and mania, may be the initial or dominant presenting symptom for a range of physical conditions. It is important to explore potential causes of organic depression in young people, such as infections (e.g. glandular fever), endocrine disorders (e.g. diabetes, hypothyroidism), metabolic abnormalities, neoplasms or central nervous system disorders (multiple sclerosis, temporal lobe epilepsy).

Mental health conditions

The clinical interview should always explore the possibility of other mental health problems — where these are suspected, further questioning or additional surveys may clarify the nature of these issues (e.g. anxiety, eating disorders). Appropriate diagnoses of co-occurring conditions can better represent the complexity of the young person’s problems and assist development of the management plan.

The differential diagnosis of subtypes of depressive disorder from each other and from non-mood psychiatric disorders can be complex in young people. Many conditions can present with symptoms of irritability and depression. Some of these are disorders in which a mood disorder or depressive symptoms are the main problem, whereas others are conditions in which non-mood symptoms better account for the observed presentation. For example, lowered mood may be brief, time limited and secondary to insight about functional impairment in an adolescent with a severe social phobia. Alternatively, a youth who feels humiliated on a daily basis because of bingeing and self-induced vomiting may appear depressed; however, the diagnosis is bulimia nervosa. This process is aided by asking screening questions about other common mental health disorders in young people (e.g. fear of situations or physical symptoms of anxiety, dieting or unreasonable fear of weight gain) and then carefully delineating which symptoms came first, and which may be secondary to a primary presentation.

Differentiation into the type of depressive disorder is important, to better match the treatment with the individual’s presentation. Combined psychological and pharmacological interventions are not warranted for brief presentations such as adjustment disorders with prominent mood symptoms.

Health professionals should be aware that the depressive episode may be a precursor to a bipolar disorder. In young people, bipolar disorder should not be diagnosed in the absence of episodes of mania that consist of a distinct change in mood accompanied by persistent elevation of mood and associated behaviour (Baroni et al 2009). If bipolar disorder is diagnosed, establishing whether the individual has bipolar disorder with a predominance of manic versus depressive relapses will have implications for medications for maintenance therapy (see Goodwin et al 2009).

Substance use

Depressive symptoms are well described during acute drug use (e.g. alcohol and marijuana) and during drug withdrawal (e.g. amphetamines and cocaine). Secondary depression is also well described in reaction to the wider psychosocial implications of substance misuse, including the probability of strained relationships with family, peers and involvement in the legal system. Excluding substance misuse is part of any diagnostic process when treating young people.

C2.2.4 Assessing depressive symptoms in young people with co-occurring conditions Mental health conditions

A challenge in caring for young people with co-occurring mental health conditions is to ensure that all disorders are diagnosed and treated. Current mental health diagnostic systems allow for reaching multiple diagnoses. Typical conditions co-occurring with depression in young people are anxiety disorder, eating disorders, personality disorder (Kasen et al 2007) and, in adolescents, disruptive behaviour disorders such as attention deficit hyperactivity disorder (ADHD) and conduct disorder.

Physical health conditions

Diagnosis of depressive disorder in young people with physical health conditions is likely to be complex as:

• the symptoms of medical illness and depression can overlap (e.g. lack of energy, weight loss, sleep disturbance); • a young person may present with depressive symptoms that are secondary to an unsuspected medical disorder; • a young person with a medical disorder may present with depressive symptoms secondary to medication (e.g.

roaccutane, varenicline); or

• a young person may present with medical symptoms, with a mood disorder being suspected if there are risk factors for depression (e.g. family history) and the physical complaints are disproportionate to other findings. Some rare developmental conditions, usually associated with known genetic abnormalities, have well-established patterns of mental health symptoms (‘behavioural phenotypes’). Examples include Prader-Willi Syndrome and Velocardiofacial Syndrome (VCFS).

Individuals with chronic physical illnesses such as diabetes, cystic fibrosis and thalassaemia, or with physical disabilities (e.g. spina bifida) may develop depression. In some instances, referral to mental health services is due

Figure C2.1 Process of differential diagnosis No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Consider further assessment and/or treatment for:

Consider diagnosis of: Are the symptoms attributable to the direct effects of a medical disorder?

Consider: infections, endocrine, central nervous system and metabolic disorders

Are the symptoms attributable to the direct effects of a substance? Consider: alcohol misuse or withdrawal, substance misuse; certain medications

Are there symptoms of a non-mood psychiatric condition?

• Eating disorders: look for common behavioural symptoms (vomiting, fasting) • Anxiety disorders or post-traumatic stress disorder: common symptoms

include worry, ruminations, irritability, sleep and concentration disturbances, fears, flashbacks, hyperarousal

• ADHD: need to distinguish from mania — young people with ADHD have generally had persistent symptoms since early childhood and disorganisation without mood symptoms

• Conduct disorder/antisocial behaviour: distinguish from mania — young people with conduct disorder have generally had disruptive behaviour since childhood

Is there a history or symptoms of mania or hypomania?

Young people with major depressive disorder who have psychotic symptoms are more likely to develop bipolar than those without psychotic symptoms

Has the young person recently experienced loss?

In situations of loss, young people may suffer from normal grief, depression, post-traumatic stress reactions or all three

Bipolar disorder Non-mood psychiatric condition Bereavement Major depressive disorder or dysthymia Adjustment disorder Depressive disorder not otherwise specified

Causative factors

Do the symptoms meet criteria for major depressive disorder or dysthymia?

Are symptoms clinically significant?dysthymia? Are the symptoms associated with a stressor?

Consider whether:

• symptoms developed within 3 months of a stressor

• symptoms persisted for no longer than 6 months after the stressor and • the young person is excessively distressed or impaired at school, work

Common issues creating diagnostic uncertainty include:

• clarification of symptomatology (e.g. deciding when lowered mood indicates depression rather than a normal response to a recent stressor);

• when numerous non-depressive symptoms co-occur with mood symptoms (e.g. food restriction, compulsions and rituals, nightmares);

• when systems issues (e.g. parental depression, problematic family functioning) are pronounced; or

• when young people have co-occurring conditions such as intellectual disability or personality disorder that can result in challenging behaviours, visible handicaps and/or pronounced educational difficulties.

Secondary consultation or referral to a mental health specialist is appropriate in these cases.