Look out for the dark side
There must be more than 1,000 young people with clinical depression in Lothian alone, and that's a hell of a lot of young people," says consultant clinical psychologist Dr Caroline Blair, head of the Young People's Unit at the Royal Edinburgh Hospital. She and her colleagues believe teachers are in a unique position to identify severe depression in pupils and are producing a pack to help.
The Young People's Unit has just completed a two-year pilot study in two Lothian schools to evaluate the efficacy of a brief intervention to help teachers recognise symptoms of depressive illness in their pupils, and to collect data on self-injury behaviour in mid-adolescence.
Results of the study, funded by the Scottish Office Home and Health Department and approved by the Lothian Research Ethics Committee, are due to be published in June, along with the teaching pack and video for schools developed by Dr Blair's colleague, Dr Stephanie Moor.
"We were approached three years ago by a guidance department worried about a spate of attempted suicides in their school in Lothian," explains Dr Blair. "We went in and did a session with teachers which went down well, leading to requests from other schools, which led us to undertake a more formal evaluation."
Clinical or severe depression affects 2 to 3 per cent of adolescents. Left untreated, it can lead to serious self-harm, drug overdosing and even suicide. Teenage suicides like Katherine Jane Morrison, a 16-year-old pupil at the Nicolson Institute in Stornoway and Suzy Barclay, a 14-year-old at Balwearie High School in Kirkcaldy, although both victims of bullying, highlight the urgency for more attention to be given to the mental as well as the physical welfare of pupils.
The big problem for teachers, says Dr Blair, is how to recognise it. "Of the 2 to 3 per cent of 14- and 15-year-olds we diagnosed as having clinical depression, not a single one was currently involved with a treatment agency of any kind."
In the pilot study, guidance and subject teachers of Secondary 3 pupils were asked to identify from class lists pupils they thought were at risk of depression. After a two-hour training session, the teachers seemed better able to identify depressed pupils.
"The evaluation data from teachers suggested they had increased their understanding of depression and confidence in recognising and dealing with depressive disorders. Anecdotal evidence from school doctors also suggested that guidance staff became more confident in making appropriate referrals of at-risk pupils.
"We do need teachers to recognise and to act. At the end of the day I believe a school health service could screen pupils for depression," says Dr Blair. "The traditional school focus on conduct disorder does not pick up on clinical depression, because a quiet or isolated pupil may not jump out as having a problem."
A milder form of depression may affect one in four adolescents and relates to exam stress or passing relationship problems with family or peers. But Dr Blair's concern is with severe cases.
"Clinical depression is a low mood which doesn't respond to experiences that would normally have a positive effect on the individual's mood. It can be accompanied by beliefs that you are worthless and responsible for all that is wrong with you," she says.
"Physical symptoms can be sleep problems, lack of energy and/or appetite, and becoming socially withdrawn. This can lead to a fall-off in school performance and suicidal thoughts and plans.
"Teachers are perfectly placed to look for such changes in behaviour and attitude, and they can also come up with different ideas of what will work in their school."
Dr Blair advises teachers to speak to pupils they suspect might be suffering from the illness. "Talk to the pupil. Ask about self-harm. If it's not a problem for the pupil, they'll probably let you know soon enough. But if there is a problem, it is likely the pupil will be relieved at being heard at last.
"The next step is to contact the school doctor or get the pupil to go to their GP and, if possible, let the parent or parents know. Ask the questions, observe and then do practical things to help, like reducing a pupil's timetable if the pressure is a major problem. Change the framework for them."
Clinical depression can occur in children as young as 11 or 12. Before the onset of puberty the gender split is even but among adolescents the ratio is two or three girls to one boy. It can be more difficult for boys to admit to, because depression is seen as a "girly" or "cissy" thing to suffer from, says Dr Blair.
"The positive message is that this is an illness which can be treated, and teachers are in a unique position to spot the problem, because young people rarely go to a GP with it. Untreated, it becomes much worse."
Clinical depression does seem to be on the increase, says Dr Blair. "The most common thought is that there are fewer emotional and social supports with the lessening impact of the extended family.
"Another factor is how the self is promoted in modern society - the so-called cult of the individual - where failure is seen as personal. Believing things are your fault is part of your depression and that doesn't take account of luck, accident, fate, social conditions, your personal environment and so on."
Dr Blair is full of praise for the positive ethos and social inclusion being promoted in schools. "This is very important. A young person needs to be happy and healthy to achieve.
"In the longer term we would like to develop more community-based projects to deal with clinical depression, because it's so common. At the Young People's Unit we do not take direct referrals from schools.
"It is important that schools contact a doctor first. That is the first port of call."
SIGNS TO LOOK OUT FOR IN PUPILS
* Inexplicable decline in school performance
* Loss of interest in school subjects l Decline in effort expended
* Giving up easily
* Complaining of not having enough energy to complete schoolwork
* Increased dependence
* Anti-social behaviour (where previously non-problematic)
* Looking and acting tired
* Alienating peers
* Withdrawing from social contact
* Concentration difficulties
* Expression of suicidal wishes
* Expecting to do poorly/fail
* Poor self-esteem
* Complaining excessively
* Low mood
* Feeling guilty
* Sleep disturbance
* Change in appetite
* Feeling weighed down
* Complaining about feeling tired
* Frequent complaints of aches and pains
CASE STUDY 1
Jill is 15 and since her first year in secondary school appeared to be undemonstrative and lacking in confidence. She always presents herself very well but has few friends, and associates mainly with one girl who similarly lacks self-esteem.
She has often been the butt of jokes in class but generally performs very well in a median position in work that relies on individual effort. It is noticeable that in physical sports or drama she lacks any desire for personal expression. She has had more absences recently but these have been accounted for by notes from home.
CASE STUDY 2
John's behaviour has never come to the notice of teachers before, but in S3 there has been an increase in reports of aggressive behaviour and one or two outbursts with teachers. It has always been thought that he could do better, but now the lack of attention to work is noticeable across several subjects. He has also skipped some afternoon lessons and may be hanging around with an older crowd. His punctuality has deteriorated and a recent note from home said he has had difficulty in sleeping and then getting up in time for school.
* CONTACTS AND RESOURCES
Depression Alliance Scotland, 3 Grosvenor Gardens, Edinburgh EH12 5JU, tel: 0131 467 3050. Can supply details of self-help groups, books, booklets, magazines and leaflets Young Minds, 2nd Floor, 102-108 Clerkenwell Road, London EC1M 5SA, tel: 0171 336 8446. Can supply titles including Mental Health in Your School, a guide for teachers and others working in schools.
Fact sheets on Depression in Children and Young People, Coping with Stress, and Suicide and Self-Harm in Young People, are available from the Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG, tel: 0171 235 2351 ext 146