Recognising and responding to adolescent depression in general practice: Developing and implementing the Therapeutic Identification of Depression in Young people (TIDY) programme

Abstract

Rates of depressive disorder in adolescents attending primary care are increasing. Most presentations are for physical complaints and concurrent depressive symptoms go unrecognised and untreated. Primary care practitioners describe reluctance to intervene due to lack of confidence and skills. This paper describes the development and implementation of TIDY (Therapeutic Identification of Depression in Young people), a programme designed by child psychiatrists and general practitioners to improve detection and intervention for depression within ordinary consultations. The paper describes the integration of educational principles and current evidence into the development of the training programme and the intervention package. The content of the intervention is described. For cases of mild to moderate depressive disorder, where patients do not require referral for specialist treatment, practitioners are trained to deliver self-help and coping strategies within a single consultation.

Keywords

Adolescent depression intervention primary care training

Introduction

Over 50% of registered adolescents consult their general practitioner (GP) each year (Kramer, Illiffe, Murray, & Waterman, 1997). Behavioural or emotional complaints account for 2% of presentations, because most attend with physical symptoms. However, research indicates a 10% prevalence rate for depressive disorders amongst adolescents in community samples (Harrington, 2002), and a 20% rate amongst samples of adolescents attending the family doctor (Kramer & Garralda, 1998). Although GPs believe that depressive presentations among adolescents are becoming increasingly common (Vandana & Ambelas, 2004), they tend to identify and react to those with severe psychological symptoms (Martinez, 2006), but fail to identify a significant number with less severe depressive disorders (Kramer & Garralda, 1998).

Depression in adolescence is associated with affective disorder in later life (Pine, Cohen, Cohen, & Brook, 1999); therefore, early intervention might alter the experience of mental ill health in adulthood. Whilst there has been considerable emphasis on training GPs to identify and manage adult psychiatric disorders, little work has addressed child and adolescent psychopathology.

Primary care offers the potential for early intervention, but research has shown that GPs spend less time in consultation with adolescents than adults (Jacobson, Wilkinson, & Owen, 1994) and they tend to only identify and respond to the minority who present with severe psychological symptoms (Kramer & Garralda, 1998). Many GPs feel that adolescents differ from adults in the way they use general practice and that they are harder to communicate with (Illiffe et al., 2008), and GPs also worry about over-medicalising adolescents’ lives (Illiffe, Gledhill, da Cunha, Kramer, & Garralda, 2004; MacFarlane & McPherson, 1995). A reluctance to discuss psychological issues with adolescents, even when GPs perceive them to be present, has been shown to contribute to poor rates of identification (Martinez, 2006; Olson et al., 2001). Furthermore, following identification many young people with psychiatric disorders receive no specific management or follow-up (Martinez, 2006). It has been suggested that health professionals hesitate to address issues when they lack confidence in their own skills or the treatments available (Dowrick, Gask, Perry, Dixon, & Usherwood, 2000). However, Zuckerbrodt et al. (2007) found primary care practitioners (PCPs) in their sample to be positive about using questionnaires to systematically screen their patients. Moreover, specific educational interventions for GPs have been shown to have sustained beneficial effects on the quality of consultations (Sanci, 2000), and training PCPs can increase the identification of depression and other psychiatric disorders in adolescents (Bernard, Garralda, Hughes, & Tylee, 1999; Zuckerbrot & Jensen, 2006).

Given the apparently high rates of unrecognised depressive disorders amongst adolescents attending general practice, we developed a therapeutic identification programme (Therapeutic Identification of Depression in Young people: TIDY) to support PCPs in identifying depressive disorders amongst adolescents and guide them in a brief psychological intervention. Since adolescent attendance for specialist treatment in primary care is poor (Westman & Garralda, 1996), we considered that an opportunistic intervention, integrated into the routine primary care consultation, might be of more immediate benefit to both PCPs and young people. This approach, in which identification of depression is coupled with a therapeutic response, offers PCPs the opportunity to give a single dose of psychological therapy to young people who are unlikely to return for counselling. The initial evaluation of the programme within a single, highly motivated practice in central London showed that it was feasible to provide training to GPs who were able to implement the programme. Importantly, it was well received by adolescents and resulted in improved identification rates by GPs (Gledhill, Kramer, Illiffe, & Garralda, 2003).

The current paper details the development of the TIDY programme and the accompanying training given to PCPs about implementing the programme. The programme and training sessions are described, and the toolkit used to support PCPs in the recognition and management of adolescent depression is discussed.

Developing the TIDY programme

The therapeutic identification programme has been developed through close collaboration between child psychiatrists and GPs over a 10-year period from 1998 to 2008. The approach taken to constructing the programme was based on a methodology for developing new technology (Wyatt, Friedman, & Spiegelhalter, 1994). The multidisciplinary team synthesised the existing knowledge in relation to changing clinical practice with the evidence pertaining to effective therapeutic approaches to produce a prototype programme. The prototype was initially ‘bench tested’ with experts to establish face validity, then it was ‘field tested’ in a highly motivated practice and refined and modified. It has been tested during 2008–2009 for feasibility, utility, acceptability and accuracy of diagnosis in four group practices in the Brent teaching primary care trust (PCT), funded by the West London Research Network and approved by Brent ethics committee (06/Q0408/92). Thirty-one PCPs participated and preliminary analysis suggests that: (1) selective, opportunistic use of the TIDY programme is followed by a small but statistically significant increase (from a very low baseline) in recognition of depression in young people attending general practice; (2) when used as a diagnostic aid, the TIDY programme has a positive predictive value of 75%; (3) the therapeutic components of the TIDY programme are used by practitioners selectively in consultations and are acceptable to young people (Kramer et al., 2010).

Designing the prototype was informed by an awareness of the characteristics of those innovations that are taken up by clinicians (Moore & Benbasat, 1991; Rogers, 2003;) (see Box 1). The techniques to enable the therapeutic identification of depressive symptoms were constructed from cognitive-behavioural and inter-personal psychotherapeutic techniques known to be effective in treating adolescents attending psychiatric services (Fombonne, 1998; Harrington, 1998; Harrington, Whittaker, & Shoebridge, 1998; Hazell, O’Connell, Heathcote, Robertson, & Henry, 1995) and from the National Institute for Health and Clinical Excellence (NICE) guidelines (NICE, 2005). The techniques were framed around standardised ICD-10 and DSM-IV diagnostic criteria for depressive disorders (Hazell et al., 1995).

Box 1.

Characteristics of innovations that change clinical practice.

Compatibility: The proposed addition to or change in clinical practice must be compatible with the values, norms and perceived needs of general practitioners.

Complexity/ Ease of use: The new clinical technique should be easy to use.

Relative advantage: The new technique offers an unambiguous advantage in terms of either clinical effectiveness or cost-effectiveness.

Trialabililty: The new technique needs to be presented in a way that allows the practitioner to test it out.

Observable results: An innovation that allows the practitioner to see the results of using new knowledge (for example, through greater patient satisfaction) is more likely to be adopted.

Reinvention: The new technique should be flexible enough to allow it to be modified, altered or tailored to local circumstances.

Image and Visibility: Using the new technique should confer credit for doing so, and make the practitioner stand out.

Voluntariness: Participation in training must be truly voluntary.

Since many adolescents will not return for a future session or attend an intervention programme, we emphasised the need to maximise the potential of the initial consultation and consider the process of identifying distress as therapeutic. This was then complemented by psycho-education methods that ‘normalise’ the experience for the young person by highlighting that depressed mood is a common experience, and reassuring them that the depression will improve. This was achieved by advising PCPs to share the knowledge that most episodes of mild to moderate depression are self-limiting. This combination of techniques was offered as the bare minimum for a response to depression, not as the only approach. The TIDY programme notes that drug and alcohol consumption and sexual risk-taking may be associated with persistent depressed mood in this age group, but these issues are not specifically addressed within the programme; practitioners are, however, encouraged to address them if they wish when they consider it appropriate to do so.

The principles of the TIDY programme

The TIDY programme is based on seven principles that PCPs are encouraged to adopt in relation to adolescents who consult them.

Consider known stressors in the adolescent’s life (e.g. major illness in the family, high-stakes examinations, breakdown of relationships, etc.).

Consider seeing the adolescent alone, if an adult, sibling or friend had accompanied them. Many adolescents are likely to present with a parent (50% of the sample in Gledhill et al., 2003), even though many prefer to be seen alone or with a friend (Burack, 2000). This is a complex task for the practitioner, who will not want to offend or worry the parent. However, many adolescents will find it easier to discuss their feelings if the consultation is confidential.

Shift the focus of the consultation from physical health to mental health/wellbeing by asking a ‘transitional question’. Moving the focus of the consultation from a physical to an emotional/ psychological enquiry is a key to our intervention. Both adolescents and PCPs may be reluctant to discuss psychological difficulties, even where they perceive these are present (Martinez, 2006). Professional barriers to raising psychological issues may include concern about the time constraints of the consultation, opening ‘Pandora’s box’ for especially difficult symptoms, such as suicidal thinking and abuse, lack of confidence in clarifying and addressing the problem, and poor access to counselling and specialist mental health services (Bower, 2003). Adolescents have expressed concern about feeling embarrassed, finding the doctor unsympathetic and being misunderstood, judged or reprimanded within a GP consultation (Churchill et al., 2000; Jacobson, Richardson, Parry-Langdon, & Donovan, 2001; Kari, Donovan, Li, & Taylor, 1997). Both practitioner and adolescent may fear stigmatisation (Jacobson, Churchill, Donovan, Garralda, & Fay, 2002). Our training package, which incorporates a non-judgemental diagnostic approach and highlights the frequency of the problem, is designed to allay those concerns while providing practical suggestions to comfortably move the focus of the consultation.

Use a general psychiatric screening question to facilitate discussion of psychological issues and to identify general distress. This question allows the young person and the doctor to discuss psychological symptoms

Focus on the core symptoms of depression. Identification of distress and diagnosis of depression will be more likely once the PCP feels they have ideas for intervention. However, they need to acknowledge the distinction between ‘normal adolescent moodiness’ and depressive disorder. Therefore, our training includes data on what mood swings can ordinarily be expected in adolescence, combined with criteria for identifying persistent depressive disorder causing impairment. We point out that disorder defined in this manner has been shown to be associated with recurrence in adulthood and significant impairment of social adjustment, even when depressive symptoms have resolved.

Diagnose depression if present and discriminate more severe cases requiring specialist referral.

If depression is identified, and immediate referral is not required, a brief psychological intervention can then be provided. Following the identification of depression, PCPs are equipped through the training process with a range of self-help and coping strategies to offer the individual. However, our intervention highlights that central to its effectiveness is the process of listening and understanding. The asking of relevant questions, helping the adolescent describe how they feel, and making links between aspects of their experiences, is in itself extremely therapeutic.

The key components of the brief psychological intervention aspect of the TIDY programme are shown in Box 2.

Box 2.

The brief psychological intervention component of TIDY programme.

Psycho-education explain what is meant by ‘depression’, how common it is, and that it is usually self-limiting.

Supply written information: We provide the depression information leaflet for young people from the (Royal College of Psychiatrists, 2004).

Offer empathy by noting recent stressors.

Give the adolescent positive reinforcement for coming to the practice and discussing their difficulties.

Advise them on what they should do at home, specifically to identify a confidant and discuss their difficulties, increase daily activities, and use self-monitoring and self-reinforcement.

Invite the young person to come back if they do not get better.

For many adolescents who are depressed, this may be their first experience of enduring feelings of sadness and they are unlikely to be able to name their discomfort, or link it with other symptoms, such as changes in appetite and sleep, difficulty concentrating and loss of interest and enjoyment in friendships and other activities. The joint construction of a narrative by the patient and practitioner that the components of the intervention advocate, although done in a very brief way within TIDY, is in line with the descriptions of how such narrative construction can enhance the healing potential of the encounter (Brody, 1994; Greenhalgh & Hurwitz, 1999). Prior to the development of the TIDY programme, one of the authors (TK) had conducted research interviews with 130 adolescents following their consultation with a GP (for any reason). In the interviews the relief experienced by the adolescents (whose emotional difficulties had not been identified in their GP consultation) through the act of helping them construct such a narrative was immediately apparent.

Within the programme we also provide PCPs with a range of potential strategies they can suggest to young people to enhance their coping. Identifying a confidant encourages the young person to seek help and support from a parent, relative or friend. As part of depression young people often withdraw emotionally from those around them without realising that this serves to further reinforce the feelings of loneliness and isolation associated with depression. Taking the first step towards re-establishing emotional contact with others decreases this sense of isolation and allows others to better understand them. Gradually increasing activity (‘activity scheduling’) is a well-established behavioural intervention that is shown to lead to improved mood (Curry, 2001). By asking the adolescent to notice how much they manage to do (i.e. self-monitoring) and encouraging them to congratulate themselves when they manage even a small improvement (i.e. self-reinforcement), the PCP is encouraging the adolescent to self-reflect in a positive way and develop a positive internal dialogue. Moreover, when the PCP praises the adolescent for talking about their feelings and encourages them to return if things do not improve, they are modelling positive reinforcement and giving the adolescent a clear message that it is appropriate to consult for emotional difficulties. We acknowledge that these suggestions would be inadequate for those who have more severe depression, and the TIDY programme recommends that such young people continue to be referred for specialist help. Criteria for cases requiring such referral are specified.

The complete diagnostic and intervention protocol from the TIDY programme is shown in Figure 1.

Figure 1.

TIDY diagnostic and intervention protocol.

Developing the training

The training provided to PCPs in the use of the TIDY programme was built on a number of educational principles. As the TIDY programme is a new technique, the training required careful attention to the methods used for professional development. Many complex interventions in health care and medical education have not been based on empirically established theory. Reasons for this include inadequate development funding, assumed lack of necessity on the part of the developers and a limited evidence base. Yet, explicit rationales for educational interventions are essential if they are to be evaluated, if the ‘black box’ effect is to be limited (Education Group for guidelines on evaluations, 1999), and the training is to be replicated in other settings.

Designing the PCP training package was based on several important principles; firstly, training needs to take account of the factors that may influence the effectiveness of educational interventions, such as individual learning styles, the caseload and demography of practices, other clinical, educational or managerial demands, the skills of tutors or facilitators and opportunities for learning from others’ experiences. Secondly, the ‘ideal’ professional development package enables the practitioner to build upon existing clinical expertise and knowledge within a busy and demanding work schedule, and is flexible enough to accommodate old and new approaches to education (Editor’s Choice, 1999). Thirdly, the new skill has to be integrated into everyday activity, and therefore needs to function as a form of ‘soft technology’, that is, a ‘taken-for-granted’ skill that is brought to bear on routine clinical tasks (May et al., 2001).

We also acknowledged that developing new practice requires the application of propositional knowledge (of the kind generated by critical appraisal of the research literature) and process knowledge (that acquired during work with patients). Furthermore, when treating patients a clinician is influenced by many factors apart from propositional knowledge, including the patient’s own knowledge of the treatment, consent, the meaning of the illness, the significance of adverse treatment effects and family or social support (Downie & MacNaughton, 2000).

Since learning tends to occur more readily through case discussion than through consideration of theory divorced from practice (Wood, Ferlie, & Fitzgerald, 1998), a key task in developing the PCP training was to produce case scenarios that illustrated, or exemplified, the potentially beneficial clinical application of propositional knowledge. One issue that is particularly relevant to recognising depression in young people is to deal with related PCP uncertainties, including the fear that diagnostic thinking will medicalise normal moodiness (Illiffe, 2008). It has been shown that uncertainty about the significance of symptoms and signs accounts for much of the variation in physician performance; therefore, training in a new intervention programme should explicitly address such issues (Eddy, 1998).

Finally, in delivering the training to PCPs we adopted a systematic practice-based approach using outreach visits, as this has been shown to be a more effective method than traditional forms of teaching (Davis, Thomson, Oxman, & Haynes, 1995). There is also clear advice that implementation strategies must use methods that are practice and community based rather than didactic (Davis & Taylor-Vaisey, 1997), which implies that training should be easily adapted to different workplace settings.

Delivering the training to primary care practitioners

The TIDY programme is presented in two one-hour training sessions held in the workplace. The rationale for adopting a therapeutic identification approach is described, and the concerns that PCPs have about recognising and responding to depressed adolescents are discussed. Because PCPs have to tread a fine line between ‘medicalising’ normal emotions and missing treatable pathology, the training sessions are structured to allow discussion of the risks and uncertainties that arise in encounters with depressed young people. They also allow discussion of methods for reducing the stigma associated with the ‘depression’ label (Iliffe et al., 2009). The video of a consultation is used to highlight the techniques used to distinguish depression from normal moodiness, and those used to deliver a ‘single dose’ of psychological therapy. The core components of the PCP training package are:

emphasising the opportunistic change of emphasis of the consultation, from a medical presentation to a psychological enquiry in a way that feels appropriate to the practitioner;

the need to use both identification and management techniques in a single consultation, with a higher level of directiveness than many practitioners might expect;

ensuring that PCPs understand the need to make the consultation comprehensive but brief.

A toolkit is provided to supplement the training and facilitate implementation of the TIDY programme. This includes a manual that describes the programme in detail, desktop aids for use during consultations and (where desired by the practitioner) a computer template containing prompts for the depression screen. Further reading is also provided in the form of a Royal College of Psychiatrists pamphlet on depression in young people (Royal College of Psychiatrists, 2004).

Discussion

Recent guidelines (NICE, 2005; Thapar, Collishaw, Potter, & Thapar, 2010) outline the need for increased identification of adolescent depression within the community and highlight the key role for primary care. We have developed the TIDY programme, which can be used by practitioners in general practice, and which will help them implement the NICE guideline advice on screening in the community. Therapeutic identification as a technique rests comfortably within the psychosocial perspective of general practice (Gulbrandsen, Hjortdahl, & Fugelli, 1997). Our approach to case identification in addition to assessing risks or recent stressors complements the NICE proposals and details a method for implementing these guidelines. The TIDY programme provides specific strategies that enable the practitioner to enter a discussion with young people about emotional issues, as well as providing a detailed mechanism for assessing whether the adolescent is suffering from a depressive disorder. It is unclear why adolescent depression should be conceptualised so differently in this respect from adult depression, where it has long been argued that the primary care has a key role to play in identification and management (World Health Organization, 2004).

Some PCPs express concerns about ‘medicalising’ adolescent distress. These often include the lack of clarity about distinguishing ‘normal moodiness’ from depression, a problem we address directly within the training package. It can also reflect concern about stigmatising young people by applying psychiatric labels. Those favouring demedicalisation suggest that sadness, even when enduring, might reflect a ‘normal’ adjustment to stressful life situations and should be understood within this context and addressed with broader social interventions, which include family and school (Horwitz & Wakefield, 2009). We encourage discussion and reflection on this complex area within the training and highlight empirical evidence that clinical interview can distinguish depressive disorder even in the context of stresses, such as bereavement. Furthermore, evidence suggests that the presence of depressive disorder arises as a result of the interaction of stress combined with individual vulnerability, meaning that an understanding based only on the presence of external stressors fails to account for this vulnerability (Brent, 2009). Since adolescents are accessing primary care, this contact provides an important opportunity for attention to their emotional wellbeing. The TIDY programme enables practitioners to feel more confident in moving the focus of the consultation from the physical complaint to the realm of emotions. While our package depends on diagnostic guidelines for identification of depression and suggests referral for those who are severely depressed or suicidal, the primary care-based intervention components are socially and psychologically based (i.e. they guide the adolescent to seek support in their social environment and provide measures to support them in managing their distress).

This debate on the conceptualisation of distress and appropriate context for intervention should include the views of adolescents themselves; however, research in this area is scanty. A small qualitative study in the US found that adolescents who had been diagnosed with depression were frustrated by ‘so-called supportive messages’ that denied their depression and expectations that they should be having the ‘time of their lives’. Adolescents displayed a range of attitudes to receiving a diagnosis with positive and negative implications for seeking treatment (Wisdom & Green, 2004). In another paper, Wisdom, Clarke, and Green (2006) describe that adolescents perceived barriers to receiving help with depression and they outline suggestions for practitioners, based on adolescents’ reports. These included a collaborative model of communication, establishing rapport, inquiring about adolescent experiences, normalising adolescent experiences, expression of empathy and exchange of information regarding depression. Gledhill et al.’s (2003) findings are in line with this. They reported positive responses from adolescents receiving TIDY. Adolescents found it helpful for their problems to be conceptualised in a way that made sense to them, that provided them with information about the problem and provided hope about improvement. Further research is required in this area and should include the views of those adolescents who have not previously accessed help.

GPs have expressed concern that ‘looking for depression’ might identify severely affected, suicidal adolescents, where there is inadequate back-up from Child and Adolescent Mental Health Services (CAMHS; Bower, 2003). However, evidence suggests that many of these cases are already being identified.

It is important to note that primary care interventions for adults with depression are strengthened by liaison with specialist services and follow-up provided by practice nurses (Gilbody, Whitty, Grimshaw, & Thomas, 2003). Therefore, we would advocate further enhancing TIDY implementation by including involvement of nurses or staff working at the interface between specialist and primary services, such as primary mental health workers.

We have demonstrated that the TIDY intervention can be delivered within the time constraints of ordinary consultations, which further dispels the myth that there is not enough time to address this issue. A feasibility study in a single, highly motivated practice showed that GPs are able to implement the intervention with adolescent attenders (Gledhill et al., 2003). Feedback from both GPs and adolescents was positive. Despite concerns expressed at the time of training, and at later interviews, about incorporating this technique into routine practice, the GPs were able to achieve this and to follow identification with components of the intervention (Illiffe et al., 2004). In the feasibility study, not all depressed adolescents received all intervention components and this was in line with the recommendation that PCPs use the components that seem most appropriate for their patient. Overall, adolescents who received the intervention found it helpful, and believed that the doctor seemed to understand what they were going through. No adolescents described negative views about receiving the intervention, which was contrary to the fear expressed by some GPs that adolescents could experience enquiry about their emotional wellbeing as intrusive. Finally, incorrect identification of someone as depressed is highly unlikely with the TIDY programme, because the guidelines on the presence of particular symptoms make the identification very specific. In addition, it is unlikely that any of the self-help and coping strategies suggested could lead to any harm.

We welcome comments from practitioners about the TIDY programme or the PCP training. The manual is freely available for use by practitioners on the following web link: http://www1.imperial.ac.uk/resources/E1A08677-A38D-49AB-A138-F1E1C97178EF/. Examples of the desktop aids and manual are available from The Academic Unit of Child and Adolescent Psychiatry, 3rd Floor QEQM Building, Imperial College, St Mary’s Campus, Norfolk Place, London W2 1PG, UK, Tel 0207 886 1145, Fax 0207886 6299.

Footnotes

Acknowledgements

We are grateful to all doctors and young people who have taken part in the development and testing of the TIDY programme.

Funding

The development of the TIDY programme and the training package has been funded by grants from the North Thames Health Authority R&D programme and by the West London Research Network.

Conflict of Interest statement

None declared.

Author biographies

Tami Kramer is a clinical senior research fellow at Imperial College London and consultant child and adolescent psychiatrist at CNWL NHS Foundation Trust. Her research interests include the development of evidence-based services, with particular attention to provision of CAMHS within primary care.

Steve Iliffe (FRCGP, FRCP) was an inner-city GP in NW London for 30 years, and is now Professor of Primary Care at University College London. He has a research interest in depression at all ages, and has worked for over a decade with the Academic Unit of Child and Adolescent Psychiatry at Imperial College on the development of simple tools to assist GPs in recognising and responding to depression in young people.

Julia Gledhill is a consultant child and adolescent psychiatrist (CNWL NHS Foundation Trust) and honorary clinical senior lecturer at Imperial College London. Her research interests focus on the interface between mental health and physical illness in children, with specific interests in the epidemiology and management of adolescent depression in primary care and psychiatric sequelae of severe physical illness in children.

M Elena Garralda is Professor of Child and Adolescent Psychiatry at Imperial College London and Honorary Consultant Child and Adolescent Psychiatrist with the CNWL NHS Foundation Trust.

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