Screening for depression in adolescents: Why do we need to screen? What should we do if we are found to be depressed?

On November 9, 2021, the Ministry of Education of China responded to the National Committee of the Chinese People's Political Consultative Conference's "Proposal on Further Implementation of Measures to Prevent and Treat Depression in Youth", clearly incorporating depression screening into student health examinations, which sparked heated discussions across the Internet.

One year has passed, and the progress of a series of adolescent depression prevention and treatment measures, led by "screening", is a question that everyone is concerned about. This article will discuss the significance of screening and the follow-up work that should be done based on international experience in this regard.

Written by | Pikachu Bulbasaur

As early as 1948, WHO proposed the three-dimensional concept of health: health is not just the absence of disease and physical weakness, but a state of complete physical, mental and social adaptation. Mental health is as important as physical health. A good and complete mental health intervention system is an indispensable part of the national public health system and preventive medicine.

Does depression just appear when you say you have it?

Figure 1: Common symptoms of adolescent depression (translated by the author) | Source: Verywell

Whether it is depression in adults or adolescents, the diagnosis depends on a combination of specific symptoms, a certain degree of severity, a sufficient duration, and an objective evaluation by a professional doctor. You cannot doubt the possibility of your illness based on just one or a few symptoms. If you have any doubts, do not rely solely on looking up relevant professional information on your own. Please seek help from family and professionals in a timely manner.

First of all, we need to distinguish between depressive symptoms and clinical depression. The former refers to the symptoms of depression, while the latter refers to depression in the clinical sense.

When faced with difficulties, setbacks, threats, and failures, everyone will show negativity, depression, and frustration to a greater or lesser extent. These emotions are not meaningless. On the contrary, they can be seen as a kind of ability, our body saying "no". Just like pain, although unwelcome, it actually sends a physiological "no" signal, allowing us to stay away from potential dangers as much as possible; negative emotions can also make us show weakness to difficulties, setbacks, threats, and failures, and withdraw from unattainable goals, thereby conserving our energy and forcing us to enter a more comfortable and safer environment to continue to survive**[1, 2]**.

Generally speaking, these negative emotions will not last too long, and they can completely disappear when the cause is eliminated or the body adjusts itself. But if negative emotions persist, gradually worsen, and become difficult to control, then we may suffer from depression.

Figuratively speaking, when a person is depressed, it is equivalent to "I am a little hungry", and "eating something" will make me feel much better; depression is equivalent to "long-term hunger makes me physically and mentally exhausted, but I have no desire to eat". At this time, relying solely on "eating" may not be effective, and medical intervention is needed to assist in recovery.

Clinically, depression has different definitions and classifications based on its causes, triggers, manifestations, etc. The fifth edition of the American Diagnostic and Statistical Manual of Mental Disorders (DSM-5) mainly defines two types of depression: major depressive disorder (MDD), which is an independent disease also known as "unipolar depression"; and the other is the depressive phase of bipolar disorder, in other words, one of the two main manifestations of another mental illness .

The depression we hear about in daily life is usually unipolar depression . The diagnostic criteria in DSM-5 are: a low mood or loss of interest or pleasure in the things around you that lasts for at least 2 weeks, and includes 4 or more of the following symptoms: significant changes in weight or appetite (not intentionally controlled); slow thinking or behavior; fatigue or lack of energy; feelings of worthlessness or excessive guilt; inability to concentrate or indecision; and recurrent suicidal tendencies [3] .

Figure 2: Common types of depression (translated by the author) | Source: Verywell

The causes of depression are complex, involving genetic, environmental, and individual factors. The proportion of each factor is completely different in different patients with depression. However, judging from the results, a theory that is currently more widely accepted is that depression is caused by a disorder in the transmission of one or more neurotransmitters in the brain, including serotonin, norepinephrine, and dopamine. Most of the classic antidepressants used in clinical practice also act on the related pathways of these three neurotransmitters**[4]**.

However, clinically speaking, depression is a disease that is diagnosed and evaluated entirely based on symptoms. Currently, there are no good physiological and biochemical tests to assist in diagnosis. There are many self-assessment scales for depression on the Internet, which are highly subjective and have large deviations. The results are actually not accurate. A more accurate way is to have two or more psychiatrists interview, evaluate, and score the patients who come to see the doctor, and then make a comprehensive judgment.

Although depression is a mental disorder, its manifestations are far more than just mental and psychological. The patient's complaints may involve various organs, including dizziness, headache, insomnia, fatigue, vomiting, constipation, pain in any part of the body, etc. This situation is called "somatization."

The goal and current situation of mental health in my country

In 2015, 173 million people in China were affected by various mental health problems, of which 95 million suffered from depression. The number of patients has exceeded that of cancer, and depression has become the second largest disease after cardiovascular and cerebrovascular diseases**[5, 6] . In that year, multiple departments in China jointly issued the "National Mental Health Work Plan (2015-2020)", the overall goal of which is to improve and perfect the mental health prevention, treatment, and rehabilitation service system that is compatible with the level of economic and social development, and basically meet the mental health service needs of the people. It specifically pointed out that the treatment rate of depression should be increased by 50% from the current level [7]**.

In 2019, the Healthy China Action Promotion Committee issued the Healthy China Action (2019-2030), which also specifically emphasized that mental health is an important part of health. The society and the government should take a number of measures to correctly understand, identify and respond to common mental disorders and psychological and behavioral problems[8].

The situation appears to be getting worse.

A cross-sectional study published in The Lancet Psychological Medicine in 2019 showed that in 1993, only 1.4% of people in China had psychological problems, while this figure was 16.6% in 2015 [6] . With the rapid development of the economy and society, people's pace of life has accelerated significantly, and the psychological stressors they encounter are increasing. There are 190 million school-age children and adolescents and 28 million college students in China. For them, academic requirements are increasing day by day, and competition with peers is becoming increasingly fierce. With such a large student base, the scale of mental health problems among minors is unimaginable.

The "China National Mental Health Development Report (2019-2020)" pointed out that the detection rate of depression among adolescents in China is 24.6%, and the rate of severe depression is 7.4%. This means that in a high school class of 40 people, there may be as many as 10 students suffering from depression, and 3 of them are severely depressed.

A statistical survey covering nearly 1,000 people in many rural areas of China showed that more than 70% of preschool children (3-5 years old) have psychological problems of varying degrees, including attention disorders, communication disorders, etc. [6] This number is not only much higher than any previous statistics, but also higher than similar studies in other countries and regions. This number is so high not only because the survey covers a wide range of psychological problems, but also because the gap in living and education levels between urban and rural areas has widened. The mental health of preschool children in rural areas is indeed in urgent need of improvement.

Generally speaking, on the one hand, common mental disorders and psychological and behavioral problems are increasing year by year, but social prejudice and discrimination are widespread, resulting in low awareness of psychological problems and low rates of medical treatment; on the other hand, my country's mental health service resources are very scarce and unevenly distributed, and a community rehabilitation system for mental disorders has not yet been established. my country's mental health work still faces severe challenges.

If you want to solve the public health threat caused by a disease, the first step is to find as many sick people as possible in the population, which is disease screening.

Depression screening and treatment: foreign experience

Although depression is an old concept, the treatment of depression has been lackluster before the 1990s. Because there are not enough good methods and drugs to treat depression, the group of patients with depression has not received widespread attention. The development and promotion of Selective Serotonin Reuptake Inhibitor (SSRI) drugs can be regarded as a milestone in the development history of psychiatric drugs. Compared with all other antidepressants available at the time, SSRI has fewer side effects and better effects, which greatly promoted the treatment of depression. When a good drug begins to be widely used, the next step is naturally to identify as many patients as possible who can benefit from the new therapy.

However, the depression screening scales available at the time had mixed results, were cumbersome to operate, lacked simple methods, and combining different methods could easily produce confusing results for doctors. It was not until 1999 that an article published in JAMA reported the "PHQ-9" scale (Patient Health Questionnaire-9, PHQ-9), which asked patients to give a subjective and rough score to their symptoms. When the total score was greater than 10 points, further professional diagnosis and treatment intervention should be considered. This study greatly increased the accuracy of depression detection and made depression screening a practical possibility for the first time. To date, the PHQ-9 scale remains an effective screening tool (Table 1) [9] .

Table 1: PHQ-9 scale | Source: https://m.medsci.cn/scale/show.do?id=291e1050f3

After the problem of screening methods was basically solved, how to deal with people who tested positive became the second problem to be solved. A series of subsequent studies discovered four important factors for solving this problem [10]:

Guidelines supported by sufficient clinical evidence.
Provide adequate education to the patient population,
There are professional practitioners of psychological medicine involved.
Implement individualized management.
In 2002, the US Preventive Services Task Force (USPSTF) began to recommend widespread screening for depression, but only if there was a mature system that could provide effective treatment and follow-up to support the screening. They believed that the PHQ-9 scale at the time was usable but not good enough, and there was a complete lack of experience in managing patients after screening. Despite this, under their advocacy, grassroots mental health practitioners began to pay attention to screening and post-screening work [10].

There are new problems. Although a group of psychiatrists admit that trying screening and corresponding management is indeed a good thing, commercial medical insurance does not include the cost of mental illness treatment in the scope of reimbursement, which prevents most people who could have voluntarily participated in screening. In order to promote the inclusion of mental illness in insurance, a large number of studies have begun to focus on the value of depression treatment to public health. For example, depression can cause some chronic complications, indirectly increase medical investment, and make companies spend more money to pay for employees' medical insurance, etc. These studies have directly contributed to the inclusion of depression treatment in insurance.

In 2016, the US Preventive Services Task Force (USPSTF) issued a notice summarizing the progress made in depression screening and diagnosis and treatment over the past decade, concluding that screening plus treatment can reduce the prevalence of depression in adults and significantly alleviate the symptoms of the affected group.

They made several recommendations based on different age groups.

1. Adults (age ≥18 years):

There is sufficient clinical evidence to show that the benefits of depression screening and subsequent treatment for this group outweigh the harms. There are many screening tools, the main tool is still the PHQ series of scales mentioned above, but the appropriate frequency of screening has not been determined.

Adults with abnormal screening results should undergo additional evaluation by a professional to determine the presence and severity of depression and other comorbidities (other psychiatric and psychological disorders in addition to depression).

Patients who are ultimately diagnosed with depression should receive mature, systematic medication and psychotherapy.

2. Teenagers (ages 12 to 18):

The recommendation level is similar to that of adults. The screening tool is mainly a customized form for adolescents, PHQ-A (Patient Health Questionnaire for Adolescents). Considering the safety issues of psychotropic drugs, in terms of treatment, only fluoxetine is approved for the treatment of patients over 8 years old, and escitalopram is approved for the treatment of patients aged 12-17 years.

For adolescents at high risk for the disease, repeated screening may be of some benefit.

3. Children (age ≤ 11 years):

For children, the total available clinical evidence is insufficient to support any recommendation.

Treatment of depression: division of labor and cooperation

At present, the most commonly used clinical treatments for depression are drug therapy and psychotherapy. For 60-70% of patients, initial drug therapy for 1-2 months will significantly relieve symptoms. After the symptoms are completely improved, stable treatment for 1-2 years or longer is still required. According to the doctor's advice, the dosage can be reduced according to the condition. For the most severe symptoms, electroconvulsive therapy can be selected. The specific choice of drugs and therapies will not be elaborated here, and the opinions of psychiatrists in regular hospitals should be followed.

In addition, there are some potential therapies that are still in the research stage, such as DBS pacemakers, which can implant pulse generators into the brain to release weak electrical pulses, stimulate relevant brain nuclei, and improve depressive symptoms [11]. Although traditional drugs can generally relieve symptoms of depression, they all require continuous medication, long medication time, large adverse reactions, and a high risk of relapse after stopping medication. In the past five years, some studies have focused on the possibility of using hallucinogens to treat depression, which has certain potential to solve the problems of traditional drugs [12], but other side effects such as addiction cannot be ruled out.

Figure 3: Treatments for depression (translated by the author) | Source: Verywell

In developed countries and regions such as Europe and the United States, the division of labor in depression research and treatment is relatively complex. Not only are there great differences between countries and regions, but the regulations in different administrative regions within a country may also differ.

Generally speaking, psychiatrists need to obtain a doctorate in medicine from a medical school and undergo a long period of specialized clinical internship. They are the main force in the treatment of mental illness. Their professional background makes them more confident in the drug treatment and psychotherapy of mental and psychological diseases. Among them, Licensed Marriage and Family Therapists also have long clinical experience, but the treatment of depression will take into account spouses, family relationships, etc., so that more people can participate in the treatment process.

Psychologists have obtained a degree in psychology. They can either conduct research in different sub-specialties of psychology or serve as psychological counselors, becoming an important part of psychotherapy. However, they have less clinical experience and usually do not have the right to prescribe drugs.

The occurrence of mental illness is closely related to the living environment, work environment, and social relationships. Some people believe that individual-based treatment is difficult to solve practical problems in a considerable number of cases and does not see the full picture of the matter. In comparison, social workers do not have relevant medical professional backgrounds, but they work at the grassroots level and have a better understanding of the community environment and life needs of residents. Their professional orientation is to help patients establish connections with the community and provide simple and timely psychological support [13]. In general, patients can seek more help, and different needs can have different choices.

Although the above occupations also exist in China, they are few in number and not widely used. Most people may have only seen them in the news or on TV, or even have never heard of them. When they need psychological support, they will not immediately think of seeking help from professionals. On the other hand, the income and social recognition of such occupations are low, and the sense of job happiness is poor, making them difficult to become the first choice for career choice. There is still a long way to go to establish a treatment system with clear division of labor and easy access for patients.

Depression screening: Is it good to know everything you should know?

When conducting widespread screening for any disease, we should not only consider the “disease cure” itself, but also comprehensively consider the investment and return ratio of screening, the social impact of screening, and the disease management after screening. This is because screening itself has its drawbacks. Labeling, stigma, interpretation of results, and subsequent treatment are crucial issues that need to be weighed [14].

The first challenge in screening teenagers for depression is how to present any abnormalities found during the screening in a reasonable way that is acceptable to the children and parents, so as to proceed to the next step of diagnosis and treatment.

In today's world where depression has not been completely destigmatized, privacy protection is undoubtedly extremely important. In a highly competitive environment, with the risk of information transmission being out of personal control, any negative label can lead to a person's failure and discrimination in employment, education, and social life. This is undoubtedly worse for adolescents who are already depressed or suffering from depression. Therefore, only by providing informed consent, standardizing the screening process, and arranging the role allocation of parents, teachers, and professionals can we hope to optimize the screening process to a level that can be promoted.

In addition, the use of psychotropic drugs is often accompanied by serious adverse reactions, such as aggravated symptoms, increased suicide risk, etc. For adolescents and younger children, there are not many clinical studies focusing on the early use of psychotropic drugs, and there is still a lack of conclusive evidence-based medical evidence on the benefits and risks of taking drugs. Therefore, the use of drugs for this group of people needs to be more rigorously verified before being included in the diagnosis and treatment guidelines.

At the same time, all those involved in screening need to realize that screening does not mean diagnosis.

"Diagnosis" means confirming the presence or absence of a certain disease, while "screening" only selects the individuals in the population who are most likely to suffer from the disease for more accurate further examination and "diagnosis". The diagnosis of depression cannot be completed with just one or two simple scales, but requires at least one professional to conduct an objective and subjective comprehensive assessment. my country has a large population. Even if screening as the "front end" of the system can be achieved, further diagnosis and treatment as the "back end" of the system still require sufficient medical resources. As of the end of 2017, there were 33,400 practicing (assistant) psychiatrists in my country, and the number of psychotherapists, medical social workers, and psychological counselors has also increased year by year, but compared with the huge population base, this number is not optimistic.

Finally, screening should not be just screening. The significance of a single screening is limited. Even if the screening does not find any problems, the social and cultural factors that can cause depression may still exist. Therefore, depression screening should also be a kind of popular science education on mental health. While testing, it can plant the seeds of "mental health is no less important than physical health" in the minds of students and parents, so that everyone can pay attention to and be alert to the signs of depression in their studies and life, prevent problems before they happen, and cure diseases before they get sick.

Outlook

We have to realize that screening may not be the ultimate means to solve the problem, but only a remedial measure that must be taken at a certain stage.

From primary school to university, our mental health education, such as frustration education, intimate relationship education, and career development education, is as unsatisfactory as the long-missing gender education. Even in the top universities in our country, there are no compulsory psychological education courses, only elective courses. And for personal development, such courses are more important than professional education. For example, how to properly deal with the psychological gap between different academic stages? What should I do when my ideas conflict seriously with my parents' ideas? When the first intimate relationship ends in failure, how can I quickly get out of depression? How should the graduating student group choose the career development path that best suits them? ... Among these numerous problems, any one may be a stumbling block to mental health and a high-risk factor for depression. Most adolescents (including children) find it difficult to have enough ability to properly deal with the above situations when they first encounter them, and they cannot seek effective help at the right time. Therefore, prevention is more important than screening.

Despite this, we are nearly 20 years behind developed countries in depression screening.

In November 2021, the Ministry of Education of my country responded to the National Committee of the Chinese People's Political Consultative Conference's "Proposal on Further Implementing Measures to Prevent Depression in Adolescents", which clearly included depression screening in the student health examination, established student mental health files, and assessed student mental health status. For the first time, the importance of adolescent mental health was raised to an unprecedented level [15]. However, the emphasis on depression screening is only an attitude, a starting point. The ultimate goal is to establish a comprehensive mental health system that starts with adolescents and covers prevention, screening, early diagnosis, and treatment. This process is not achievable through individual efforts, but requires the common attention of the entire group. The road is long and difficult, and before that, each of us has the responsibility to understand, help, and advise.

References

[1] Bledow R, Schmitt A, Frese M, Kühnel J. The affective shift model of work engagement. J Appl Psychol. 2011 Nov;96(6):1246–57.

[2] Forgas JP, East R. On being happy and gullible: Mood effects on skepticism and the detection of deception. J Exp Soc Psychol. 2008 Sep;44(5):1362–7.

[3] Depression Definition and DSM-5 Diagnostic Criteria [Internet]. [cited 2021 Dec 9]. Available from: https://www.psycom.net/depression-definition-dsm-5-diagnostic-criteria/

[4] Disner SG, Beevers CG, Haigh EAP, Beck AT. Neural mechanisms of the cognitive model of depression. Nat Rev Neurosci. 2011 Jul 6;12(8):467–77.

[5] The Lancet. Mental health in China: what will be achieved by 2020? Lancet. 2015 Jun;385(9987):2548.

[6] Huang Y, Wang Y, Wang H, Liu Z, Yu X, Yan J, et al. Prevalence of mental disorders in China: a cross-sectional epidemiological study. Lancet Psychiatry. 2019 Mar;6(3):211–24.

[7] Interpretation of the National Mental Health Work Plan (2015-2020)_Interpretation of policies and regulations_Policies_Chinese Government Network
http://www.gov.cn/zhengce/2015-06/18/content_2881440.htm

[8] Healthy China Action (2019-2030)
http://www.nhc.gov.cn/guihuaxxs/s3585u/201907/e9275fb95d5b4295be8308415d4cd1b2.shtml

[9] Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999 Nov 10;282(18):1737–44.

[10] Culpepper L. Does screening for depression in primary care improve outcome? Curr Psychiatry Rep. 2012 Aug;14(4):345–52.

[11] Krauss JK, Lipsman N, Aziz T, Boutet A, Brown P, Chang JW, et al. Technology of deep brain stimulation: current status and future directions. Nat Rev Neurol. 2021 Feb;17(2):75–87.

[12] Perkins D, Sarris J, Rossell S, Bonomo Y, Forbes D, Davey C, et al. Medicinal psychedelics for mental health and addiction: Advancing research of an emerging paradigm. Aust NZJ Psychiatry. 2021 Dec;55(12):1127–33.

[13] https://www.apa.org/ptsd-guideline/patients-and-families/psychotherapy-professionals

[14] Final Recommendation Statement: Depression in Adults: Screening | United States Preventive Services Taskforce [Internet]. [cited 2021 Dec 18]. Available from: https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/depression-in-adults-screening

[15] Letter on the reply to Proposal No. 3839 (No. 344 on Education) of the Fourth Session of the Thirteenth National Committee of the Chinese People's Political Consultative Conference
http://www.moe.gov.cn/jyb_xxgk/xxgk_jyta/jyta_twys/202111/t20211104_577685.html

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