We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Seeking autonomy and social connection, risk taking, and identity making, the brain in adolescence is unique. It's primed to absorb and learn from the environment, and that means the teenage years are a chance to improve a young person's trajectory. This new series of Inside the Teen Brain explores how neuroscience can inform our understanding of young people's home, school, and life experience. In conversation with leading professionals, we answer three big questions-- what's the background, so what, and now, what? I'm Dr. Jane Gilmour, and this episode is called Depression. Through the lens of the teenage brain. Well, now our first big question asks, what's the background? We are using a developmental lens, yes, that's true, but these are no rose-coloured glasses. Globally, around 3.4% of adolescents have depression, and recently, rates have increased, particularly in girls. Important for our exploration of the teen brain. Depression in adolescence may present in characteristic ways. For example, irritability and shifts in sleep pattern are more likely in depressed teenagers as compared to adults. The complication here is that these same patterns fit the stereotype of a teenager, and so step changes that could flag a mood disorder may be disregarded. Orchard and many others show that changes in sleep quality and fatigue may be a precursor, core feature, or an area for intervention. Emerging data indicate distinctive patterns in several key brain networks may also be predictive. For example, a healthy teenage brain has heightened emotional reactivity, a clever system to learn about the world. But levels of reactivity typically decrease during the teenage years. In contrast, young people at risk of depression have greater activity in the amygdala, the fear centre of the brain, and this may be due to environmental or genetic influences. It's worth noting here, too, that the literature describes a hypothesised latent risk factor for all psychological disorders, the so-called P factor, which may prove important in understanding the high co-occurrence of mental health conditions in adolescents. Social media's controversial reputation in connection with mental health is relevant here. For most teens, there are no strong data to show that social media predicts depression. Indeed, generally, it has a neutral or positive effect. But for a small group of vulnerable, socially isolated young people, using it excessively impacts mood. We might hypothesise that spending a lot of time alone, watching a heavily curated social world would have obvious effects on mood. But remember, phone use may serve as a proxy for underlying mechanisms. If a teenager is using social media, they're neither sleeping nor exercising. Both of which are key to good mental health. Miller and Campos review argues that depression during adolescence may prove more impactful precisely because of that poorest quality of the teenage brain. We might hypothesise, too, that the very same sensitivity offers a window of opportunity for intervention. And indeed, Ricard Bell's group calls for a developmentally specific assessment and treatment system, focusing on aspects of self-perception, a position that has some support. Because when models of intervention tested largely on adults are applied to adolescents, the effects are somewhat weaker. Does this reflect a qualitative difference in the adolescent depression picture, or perhaps an indication that we need to tailor our delivery to the specific needs of this developmental stage. Depression erases passion, taking with it the heartfelt goals of adolescence, which form the foundation of a well-integrated adult. As Solomon said, young people with good mental health may not always be happy, but they will be vital. So as we move to the next big question, we ask, so, what? So what can we do to help depressed young people reclaim their vitality? To help me answer this question, I'm delighted to welcome Victoria Pile, Clinical Psychologist and Senior Lecturer at the Institute of Psychiatry, Psychology, and Neuroscience at King's College London. Her special interests focus on improving access to effective early intervention and co-designing treatments for young people and underrepresented communities. So welcome, Victoria. There's a lot to do. Let's get started. Brilliant. Thanks, Jane. It's lovely to have you. We have a whole list of questions. We may not get through them all, but there is some urgency in some ways to these questions, because I raised the idea of the recent changes in identified rates of emotional disorders in young people. So how does depression specifically fit into that picture? Yeah. So as far as we know, depression fits squarely in that picture, so obviously, when we're talking about prevalence rates, it really depends on the age that you're defining, but also how you're defining depression. So depression can be everything from a very narrow major depressive disorder diagnosis, but also includes things like elevated symptoms of depression. So if we look at elevated symptoms, a recent systematic review showed that quite clear evidence of increases. So from 2001 to 2010, rates were around 24%, which is global point prevalence of elevated depressive symptoms, and from 2010 to 2020, it rose to 37%. So whilst we're still trying to understand and figure out this picture, there's definitely a bit of a message that, yes, unfortunately, rates seem to be going up. So as you're talking about it, you're somewhat excluding the idea of different definitions or different, let's say, changes in the methodologies that are being used or changes in criteria, that they are true differences in rates. Is that fair to say? Yeah, it looks like there's true differences. So however you define it, whether it's your major depressive disorder, your emotional disorders more generally or your elevated symptoms of depression, we see a increase over the last few years. It is complicated. There are different rationale and reasons. It could be that increased awareness means that we're picking up the symptomatology more. But certainly, in terms of what's being diagnosed, what's being picked up in terms of elevated rates, it looks like it's increasing. Why that is, is a different question. And if you were to hypothesise-- now, of course, I appreciate your using conjecture, but what would you suggest me underlying that change? I think there's a huge number of different reasons, and I would guess that it's a complicated melting pot of all of those different reasons. So you mentioned things like social media, which is normally the one that gets highlighted, but it could also be other things. It could be academic pressure, changes in our working patterns as parents. There's so many. There's a hugely long list of different reasons. COVID is that period of where we were isolating is also something that's often cited. I don't think we really understand or know why. And I think it's very important to highlight that there are a multitude of factors, and that, somehow, gets lost, certainly, in the mainstream messaging, less so, of course, in the academic literature. I also wonder, and again, this is a hypothesis, about a lack of certainty. Because I think there's more discussion about, let's say, climate change and political shifts and so on, and that lack of certainty, I wonder if that has an impact on young people who are listening and thinking about a shift in their world, and if that represents a loss. Because we know, often, depression may be associated, in particular, with a loss for young people. I don't have data to support that, but it's an observation, I guess, I'm making from clinical practise. Now, you are talking specifically about depression in adolescence. I touched on that a little. Can you explore that specific presentation in adolescent for us, please? Yes, it's a really interesting question because do we know that depression and adolescence is different from adult depression? And there's certain things that suggest it is. So first of all, we know that the peak rate of velocity, so how quickly symptoms increase lies in adolescence. So it's around 13 and 1/2 for females and about 16 for males. We also know that adolescent onset of depression is significantly related to much worse outcomes than adult onset of depression. So when depression starts in adolescents, it's much more likely to impair functioning than when it starts in adulthood. And we also know that our interventions for young people are not as effective as our interventions for adults. So it looks like it is different. And there's been a number of different ways that this has been explored. One of the first obvious things is comorbidity. So young people are much more likely to present with other disorders. So around 75% of young people presenting with depression will also have an anxiety disorder. We know that depression is hugely heterogeneous. And there was one paper that suggested across the lifespan, that you could have up to a thousand different symptom presentations, which would all result in the same diagnosis of depression. And so academics and clinicians have started to try and explore this. And one way is through mapping the symptoms of depression that we see. And so what that tends to show is that, in adults, you get central symptoms of emotional distress. So things like sadness and academia. Whereas, in young people, the central symptoms are more self-hatred, loneliness, and pessimism. But we can also look at this a bit differently, right? So it depends how-- like you said earlier, it depends on the methodology you're using to try and understand the question. So there was another study that looked at cohort data, and it showed that physical symptoms are things like changes in sleep, appetite, or energy were more likely in young people than in adults. And then as you referenced right at the beginning, irritability is also thought to be more increased in young people. So it really depends on what methodology you use to look at how the symptom presentations are different. But what we do know is that adolescence is this really unique period of profound social, psychological, and biological changes. And so it is likely that depression might look quite different in young people compared to adults. I mean, you described that so succinctly, because it's a very complex literature, and it's both complex and enormous. What you are pointing towards is that there may be something specific about adolescent onset depression, which is qualitatively different, because it points to a poorer outcome in adulthood. So it's not simply an early version of the same condition, potentially, with that. Is that fair to say? Yeah, I mean, I think in my personal opinion, adolescent depression, when it onsets in adolescence rather than adulthood, could be quite different. And it might be that it's because those thinking processes are more likely to become entrenched during adolescence and adulthood. But we also know that many adolescents will have one episode of depression and never experienced depression again. So I think what we also have to remember is that depression is recurring and remitting, which makes it a particularly tricky disorder to understand and to think about in terms of those different pathways. And you talked a bit about that these symptoms of irritability, potentially, and sleep disruption, as well as we're hypothesising, or at least there's data to support that, potentially, these may be differentiating features or at least occur more frequently in adolescent depression. Now, of course, that overlaps with the so-called grumpy teenager stereotype. So if we were to create a public information message here and now, it's perhaps suitable for parents or teachers, how could we message that to differentiate between the grumpy teenager stereotype and flags for a mood disorder. Yeah. So if it's all right with you, I'll answer this really directly, and then I just want to slightly unpick that stereotype as well. Yeah. And so to answer it directly, grumpiness, or moodiness, or whatever you want to call it, comes and goes. Whereas, depression really lingers, and it will also narrow a young person's world. So we tend to think of grumpiness or moodiness as reactive, so it usually is in response to something that's happened. But it also doesn't last for a significant amount of time or narrow that young person's world. It doesn't fundamentally change who they think they are or how they think their futures will be. Depression is different. Depression is persistent. We usually talk about symptoms lasting at least two weeks, but it also impairs functioning. So it starts to change the young person's engagement in their relationships, activities, the pleasure that they get from previous hobbies that they enjoyed, and also potentially their educational attainment. So if it was a public health message, I'd be thinking about the patterns over time, not just of day-to-day today changes. But I guess to also unpick the idea of teenage grumpiness. What we know with depression is it exists on this continuum, right, from your everyday low mood to your severe major depressive disorder. And whilst we do put in an arbitrary cut off for the diagnosis, that doesn't reflect the impact that those symptoms might have on our functioning or the distress that it causes. And so, sometimes, young people, when they're distressed, that may show up as irritability or grumpiness. It's almost like a behavioural manifestation of something that's underlying. And we know that we're not very good at picking up at depression in young people. So potentially, I'd always encourage people to approach that grumpiness or irritability as an opportunity to have a conversation and explore what might be going on for young people. And I couldn't agree more, Victoria, because, actually, whether a mood disorder underlies that, or there's something else going on, having that curiosity about thinking about what's underneath the behaviour for a teenager, whatever their mental health status is always a good idea. And it's almost invariably something that will increase the quality of the relationship that you have with that young person. It's not about telling off. It's about asking why. I want to come back to something else that you describe that is particularly, perhaps, characteristic of the teenage experience of depression. And that is thinking about self-loathing. Because we know that adolescence is a time for identity formation, and that referencing and considering oneself is a developmental process. Can you talk a bit more about the significance of that developmental drive in the context of depression? Yeah. So, yeah, absolutely. Adolescence is a hugely important time for the development of the self, and it's likely that our self-identity or sense of self becomes increasingly differentiated and complex over the course of adolescence. If you'll let me, I might narrow it down to the idea of self-perception. So self-perception is the personal qualities that we hold about ourselves, but importantly, the value that we place on those personal qualities. And so we know that self-perception is really core in terms of our understanding of depression. It's central to lots of our psychological models, and it's also a symptom of depression. So if we have beliefs, such as I'm a failure, I'm not good enough, I'm unlikable, all of those things are both symptoms of depression and likely to maintain it. What some of our research has also shown-- so Becca Dean, particularly, did a longitudinal paper, looking at the links between changes in perception, and that showed to predict changes in depressive symptoms. So it may also be a risk factor for depression. What she also did was interviewed young people with a history of depression and ask them about the pictures that they have of themselves, the mental images that they hold about themselves. And to quote one of the young people, they said, "When I picture myself, I just see Black and white and dull." And so what young people talk about is having these autobiographical experiences that are then extract a meaning from that then comes to define their sense of self. Could be something a bullying incident or failing an exam, and they extract from that a meaning of I'm a failure, or I'm not good enough. And we know that those sorts of beliefs, when they become stable and core could confer risk for depression. But what that also tells us is that adolescents might be a huge period of opportunity to change and to shift some of those beliefs. So if we can shift to a more compassionate or flexible view of ourselves, then perhaps, we can decrease the chances of future depression. And that's what young people tend to tell us. So when we interview young people, who have taken part in some of our therapies, they tell us about how self-acceptance and self-confidence is a hugely important and meaningful shift for them. So I do hope that we can increasingly think about self-perception, when it comes to the development of our treatments. And that's a very powerful, and what a model for understanding the vulnerabilities of the teenage brain and using those vulnerabilities in order to leverage the power of the teenage brain. It's a beautiful formation of the power of identity formation and self-concept, specifically here, and how that could be-- the very vulnerability can be shifted, and we can have that compassion for oneself. It's really very powerful. I want to talk a little bit more about treatment as well. I mean, we know that, as I said, the teenage brain has a variety of different unique characteristics. It's passionate. It seeks novelty. It's peer-orientated. And you've started to touch on some of those, leveraging some of these characteristics to adapt, perhaps, interventions. Can you talk a bit more about that? Because that's fascinating. Yeah, it's really important, right? I think this is absolutely essential, when we're developing interventions, because adolescents are not just small adults. Their brains are-- as you've said, their brains are rapidly changing. They're much more sensitive to certain things, like peer feedback and emotion. But historically, what we have done in psychological interventions is taken adult therapies and try to translate them down to our young people. And that, perhaps, explains why the effect sizes, or how effective our treatments are. It's maybe not as good in adolescents as in adults. And so there has been an increasing shift towards codeveloping interventions with young people, for young people. And so my work is very much looking at young people with elevated symptoms of depression and try to develop interventions for that group. And so what they talk about is having much more active and experiential therapies, but also having ones that are briefer and focused in on something, whether that's symptoms, whether that's a psychological mechanism, or whether that's a particular skill. And that might not be true for every kind of different type of depression or every severity of depression, but certainly, for our group, that seems particularly important. But as you said, the other thing they highlight is being able to harness those processes that adolescents are naturally doing. So that's things thinking about our future, about peer connection, and for us about emotional mental imagery. So this is the bit that I'm particularly interested in. So emotional and mental imagery is our ability to generate these sensory experiences within our mind. And they might be really deliberate. So when you're trying to plan a holiday or something, you might imagine that holiday. You might imagine going to the airport and the steps that you need to get there. But it might also be distressing, intrusive images that pop into our mind, when we don't want them to. So we know that intrusive images are really common in young people with depression. And we know that, in depression, you're less likely to imagine these positive future images. But we also know that adolescents harness imagery-based processes more than adults, and that they may have less cognitive control over their intrusive images. So potentially developing imagery-based interventions for this group could be really powerful. And that's what we've been doing. So we've developed an intervention called Imagine, which shows really strong clinical promise. And we're continuing to evaluate it. But I guess what this, hopefully, highlights is that if we can try to develop these more precise and developmentally informed intervention, perhaps we can start shifting the tide and getting those effect sizes that are much more consistent with the adult literature. I'm so intrigued by what you're describing there. I mean, the co-creation is obviously key to its creativity. So getting young people to say, oh, this is really helpful for me. It's experiential. Because, actually, if I think about the classic cognitive behavioural framework, let's say, which does have an evidence base, but it is didactic, it can be somewhat dry, unless it has is delivered with some creativity. And so it makes sense that changing that or shifting it to some degree, of course, there are some strong parallels, quite rightly. But the idea of using imagery is so powerful. Because, also, it has an individualised aspect to that, which, I think, young people will really respond to it. You said you've started to evaluate it. Could you give us some tasters of what the data are showing? Yeah, of course. So we ran a feasibility randomised control trial so that's where we evaluate. Imagine against a control intervention. So it's an active-- really important for us is an active control intervention because most of the literature, it will be an intervention versus treatment as usual, whereas, we deliver a psychological intervention for young people with depression, which is nice recommended. So in that feasibility trial, we had 56 young people randomised to treat those two groups. And we showed really large effects at follow up. So eight weeks, it was 1.34 effect size, which is very big compared to literature that was maintained. It's a very rare. Yeah. That's very rare to find that in psychological literature. So that's exciting. Yeah. And then a couple of months ago, we've just finished the bigger trial, so a phase IIb randomised control trial. And so, yeah, I'm getting the results back any day. Wow. Well, perhaps, you can come back and talk to us a bit more about that, because I think that particularly for our audience, when we're thinking about young people holds enormous promise. And this is really-- a question related to this is, we know that lots of young people don't receive treatment for their depression, although it's highly treatable. How can we address this? And I know that one of your passions is about connecting with underrepresented groups. So what advice could you give us in terms of getting more young people into services? Yes. Yeah. So access is a huge problem, right? So we know that around 75% of young people won't ever get any formal help for their depression. But importantly, we know early intervention is super important. So if a young person receives help at age 14, there'll be seven times less likely to meet diagnosis for depression at age 17 than those who get no help. So we know it's important to get in early, but we also know we're not doing a particularly good job at getting that help. And that's partly because, at the moment, our evidence base is for these-- well, our gold standard therapies are months and months of therapy with very experienced clinicians. And so what that's meant is very long waiting lists, but also really high threshold for care. Wind back a little bit, what's also important is that the effectiveness of our interventions isn't that good. So in terms of depression being, I think you said a highly treatable disorder. Meta-analysis suggests that, actually, our gold standard interventions are only a little bit more effective than treatment as usual. And a recent one by Pim Cuypers showed that 60% of young people who receive those gold standard treatments don't get better. So actually, we've got two problems. We've got, first of all, access, but then, we also have how do we make these interventions as effective as we possibly can. In terms of access, what's been explored, particularly at the moment is school-based interventions, so taking those interventions out of the clinic and into schools. And that's really consistent with the NHS 10-year plan. So what has happened in services is an increased drive towards school-based mental health practitioners, delivering low intensity, scalable interventions for young people. And I think that does really help in terms of accessing a wider range of young people. What's also been a change in the literature is to more protocol driven interventions. So ones that rely less on this years and years of experience and so can be delivered by a wider range of practitioners. So [INAUDIBLE] is doing lots of work around digital single session interventions that are anonymous. And so that's another way to reach those groups, that we might not be historically reaching. In our work, we do deliver interventions in secondary schools, an inner city London. And actually, our uptake is very good across different ethnicities, across different socioeconomic groups. And so there are lots of ways in which we can rethink how we're delivering interventions. In terms of effectiveness, we've already talked about that a little bit, but I guess it is about this can we target specific symptoms or psychological processes that we think are particularly important. So that might be things like sleep, or it might be things like repetitive negative thinking and rumination or self-compassion. So I guess probably what we need to do is be really open to try and figuring out where do we offer these, how early can we get in, and what exactly do we deliver. Yeah, that's very well put. I like that idea of rethinking, so we do have a body of work, but we need to shift and shift strategy according to our evidence base. I like that position. When we talk about rethinking, as we come towards the end of our discussion, I want you to describe something in your professional life or outside work, if you prefer, that you had to rethink, perhaps something that didn't go to plan, and describe what you learned from it. Yeah, of course. So if it's OK, I'll give you an example, a clinical example, but it was in the context of a research study. So I was working with a young person, and we were trying to develop really rich, positive future imagery. And so to do this, what was important to us by protocol was to develop the future image and to think about the path to get there. So the things that could go well might not go so well, how you meet those challenges, and to develop a series of images along the way. So this young person talked about wanting to be a doctor, and we developed this really beautifully rich image of that. I thought the session went well. She came back the next week, and we were reflecting on the previous week. And she said, it was helpful, but I don't want to be a doctor. And I thought, oh, dear, where do we go with this? So we explored it. And what she talked about was what the process had done, is it been able to open up her future thinking. So she could now see a number of different pathways in her future and a number of different end goals within that. And she spoke about how before she rigidly be attached to this very underdeveloped image of being a doctor. That was unhelpful, and she felt was putting lots of pressure on her. So it certainly didn't go to plan, but she found it helpful. And what that led to was us doing a whole series of qualitative interviews with young people to try and explore that process that might be going on. And I've got a quote from a young person, because they say it much better than I could. So he said, there's every step of stone, and every stepping stone, one of them could be loose and could go back one. So it's not just about looking at the future. It was about looking at it and making a way through. It's how you deal with that step backwards that leads you to going forwards. And I guess I thought that was a nice quote in terms of your question, but also in terms of it's about the process. It's not just about developing these isolated images for young people, but it's about opening up the possibility of thinking about the future. Victoria, I think what a brilliant and inspiring story and a fantastic quote from that young person who may well go on to do some other very interesting things, if they have the capacity to narrate in that way. But what you're describing is something really powerful about that opportunity to rethink and improve because, perhaps, something didn't go to plan. And I'm also struck by the idea that young person felt safe enough to come back and say, hold on a minute. This isn't quite what I meant, and that is a great testament to the working space that you created for them. That's really wonderful. Let's come to our final question. Can you give me a single takeaway? Now, this could be about your approach in academia or your changing clinical practise that could improve our offer to young people. Yeah, absolutely. So I think, for me, it's about asking young people how they see themselves. So whether that's their memories of things that have happened, or how they imagine their future, and not just asking about how they feel. So we tend to ask, how are we doing and get very focused on our feelings. Whereas, if we can expand out that conversation and think more about self-perception and future-focused, thinking, perhaps, we can have slightly different conversations that also help. So I'm not saying don't ask about the feelings, but what I am saying is let's try shifting to different conversations at different points to try and open up some of that flexibility. That's wonderful. Oh, Victoria, thank you. What a superb session. It leaves us with data informed and actionable advice. And that is just the way we like it. So, thank you.