Diagnosing and treating depression in the late adolescent/early adult period can be complicated and confusing. Research models provide some important data, but the research has to be interpreted through proper clinical acumen. The DSM system has given us guidelines to diagnosis, but in this age group, as in others, many patients don’t fit cleanly into any specific diagnosis. As research is done using diagnostic criteria, it can be difficult to apply the research to clinical practice. Furthermore, research outcome is measured by statistical significance, which can be quite different from clinical significance. Thus, integration of research knowledge with clinical expertise is crucial in assessing diagnostic and treatment practices.
Most adolescents and young adults with depressive symptoms do not fit well into DSM criteria. True Major Depressions are rare in this age group, as on careful assessment consistent depressed moods are uncommon. It often takes many sessions to discover the true depressive picture. What one often finds is that even when the patient reports long-standing consistent low mood, that in actuality, the patient’s moods are situation dependant. The severity of the depressed mood, especially on an initial assessment, is not suggestive of a particular diagnosis. Adjustment disorders are common, though again moods can be highly variable. In this population it is probably more accurate to speak of depressive states rather than specific diagnoses. Depressed patients are likely to show recurrent depressive states lasting from hours to a few weeks, intermingled with normal moods. The variable, but recurrent nature of these depressions often doesn’t meet the criteria for Major Depression, Adjustment Disorder, or Dysthymia. However the intensity of the depressed moods, and corresponding loss of motivation, energy, and concentration will often look on superficial examination like a Major Depression. Depression research in this group, which has consistently shown poor responses to medication, has probably been limited by inadequate diagnostic interviews resulting in too much diagnostic variance in the research populations. From a clinical perspective, in this age group, like in the general adult population, true Major Depression with Melancholia appears to respond well to medication. Other diagnoses tend to show minimal responses.
Therefore, apart from a small, properly and clearly diagnosed population, one is left trying to treat the individual with depressive states. These states appear to be due to a combination of temperament, psychodynamics, and psycho-social factors. These states can roughly be classified into depletion states, fragmentation states, and mourning states.
Depletion states occur when an individual suffers a psychologically significant loss to his self-esteem. Mood declines, often quite dramatically, energy, motivation and concentration deplete. Most people need regular refueling of their self-esteem to feel content within themselves. This refueling may be internally generated through one’s inner concept and experience of one’s abilities and achievements, both emotional and practical. However even the most secure individual will need some external validation of his self in order to maintain confidence. Individuals with more fragile self-esteem can be extremely dependent on outside validation in order to feel confident. Even minor insults to one’s self confidence can be devastating to some people, especially if they have lost regular support networks. Repeated insults can lead to severe depressive states, though even in these, fluctuating moods are common. As energy, concentration and motivation decline, further failures are inevitable, leading to further narcissistic injuries. Thus, a downward spiral can easily occur in susceptible individuals. Therapy in these individuals is aimed at recognizing the injuries, both past and present, helping the person control self-sabotaging behavior, and reconnecting the person with more positive aspects of their self concept and with more reliable support systems. Medication may help in softening anxiety and dampening depressed mood.
Fragmentation states are related to a loss of psychic security. They can occur in almost any individual when there is a severe trauma. Individuals who have had very insecure or traumatic backgrounds can be very susceptible to these states, which may be provoked by relatively minor events. These states are characterized by high anxiety and severe dysphoric moods. The individual may feel suicidal, or may exhibit behavior aimed at alleviating the mood, such as binge eating or drinking, drug abuse, infliction of pain or self-mutilation. Dissociative states may be seen. Suicide is rare, though suicide attempts may be frequent. The attempt by the individual is to feel intact again, not to destroy themselves. Moods can fluctuate considerably, as can energy, concentration and motivation. The dysphoric states can last a few hours to a few days, though a person may be left feeling depleted or disconnected in between the acute states. In therapy it is crucial to provide a secure, consistent environment for the patient. Therapy is aimed at dealing with past and present disruptions to a basic sense of security. Acute life traumas are explored, but usually only when a sense of trust has been established and when fundamental security issues have been settled. Focusing primarily on acute traumas can be highly disrupting, and can prevent the individual from dealing effectively with their daily life.
Mourning states occur in response to a loss of a significant other or social milieu. These states can occur after a separation from home, a breakup, a death, or the loss of friends. Mood will tend to be low, possibly severely dysphoric, though the level of anxiety is usually lower than in the other state. However, it is possible that a person may experience a sense of fragmentation or depletion in response to a loss. Thus symptoms may be mixed. Motivation is usually compromised, as in face of the loss, little else feels important. A person may wish to isolate themselves or may feel anxious about being alone. Fears of illness, injury or death are common. Sleep disturbances, especially difficulty in falling asleep, frequently occur. When the loss is severe, these states may last for many months. In therapy, the person is helped to mourn the loss, deal with ambivalent feelings, and reconnect with the world. Medication may be useful to regulate sleep. Sometimes anti-anxiety medication may be helpful in acute situations.
These days many treatments have tended to focus on symptom reduction, using DSM criteria and research oriented scales to measure outcome. These treatments are limited both by the accuracy and the relevance of the diagnoses, the actual significance of the symptom reduction, and the lack of emphasis placed on emotional growth. Treatments that primarily promote control of symptoms tend to discourage patients from assessing their life, their needs, and their emotional issues. Patients are also sensitive to overt or covert messages as to the expectations of the treating practitioners. Patients will often comply with expectations, hiding true symptoms from practitioners. When a patient is given only a few minutes to talk about their problems, they will tend to focus on acute symptoms, leaving out more complex problems. In clinical practice, frequently one gets a totally different picture of an individual’s life when one gives the patient the message that one have the time and interest in listening. There are no accurate shortcuts in assessing an individual’s emotional life.