major depressive disorder (mdd) is a debilitating condition that has been increasingly recognized...
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Major depressive disorder (MDD) is a debilitating condition that has been increasingly recognized among youth
Prevalence of current or recent depression• 3% among children• 6% among adolescents
As many as 1 in 5 teens have history of depression at some point in adolescence
Adolescent-onset MDD is associated with• ↑ risk of death by suicide• ↑ suicide attempts• ↑ recurrence of major depression by young
adulthood• ↑ risk of substance abuse
MDD also associated with• Early pregnancy• ↓ school performance• Impaired work, social, and family functioning
during young adulthood
Despite significant health burden of MDD, the majority of depressed youth do not receive any type of treatment
Diagnosing depression in children is difficult because of their limited language abilities
Many barriers to adolescents receiving specialty mental health services
Primary care settings have become de facto mental health clinics for adolescents
Primary care clinicians feel inadequately trained, supported, or reimbursed for management of MDD
Insufficient evidence for USPSTF to recommend for or against routine screening of children and adolescents
If patients are to benefit from screening, physicians should have systems in place to assure accurate follow-up
According to the USPSTF, an affirmative response to 2 questions
• May be as effective as using longer screening measures or
• May indicate the need for use of more in-depth diagnostic tools
1) “Over the past 2 weeks have you ever felt down, depressed, or hopeless?”
2) “Have you felt little interest or pleasure in doing things?”
Depression screening measures do not diagnose depression, but provide• An indication of severity of symptoms• Assess the severity within a given period of
time Depression screening measures for
children and adolescents are generally appropriate for children who are• > 7 years old• At > 6th grade reading level
Measure
Age appropri-ateness
Reading level
Spanish version
# of items
Time to complete (min)
Children’s Depression Inventory (CDI) 7 – 17 1st Y 27 10 – 15
Center for Epidemiological Studies-Depression Scale for Children (CES-DC)
12 – 18 6th Y 20 5 – 10
Center for Epidemiological Studies-Depression Scale (CES-D) 14+ 6th N 5 – 10
Reynolds Child Depression Scale 8 – 12 2nd Y 30 10 – 15
Reynolds Adolescent Depression Scale 13 – 18 3rd N 30 10 – 15
Beck Depression Inventory (BDI)14+ 6th Y 21 5 – 10
Pediatric Symptom Checklist is an alternative tool for screening children for psychosocial problems• Not specific for depression• 35-item checklist• Parents complete
Persons scoring above established cutoff level should be interviewed for depressive disorders in DSM-IV-TR• Major depressive disorder• Subclinical or minor depression• Dysthymia
Interviews are necessary because screening does not address:• Conditions with symptoms common to
depression• Duration of symptoms• Degree of impairment• Co-morbid psychiatric disorders
In cases of mild depression, consider a period of active support and monitoring before starting other evidence-based treatment• Weekly / bi-weekly visits x 6-8 weeks• A sizable # respond to nondirective therapy
and regular symptom monitoring• Essential when family/patient refuse treatment
The GLAD-PC toolkit provides additional guidance on providing active support
For moderate to severe cases, clinician should recommend:• Treatment• Crisis intervention (as indicated)• Mental health consultation immediately• No period of active monitoring
Start active support and treatment when there is a lengthy wait list for mental health service
Once referral is made, primary care doctor should remain involved in the follow-up
Appropriate roles and responsibilities for ongoing management by primary care and mental health clinician should be:• Communicated• Agreed upon
Help patient and family arrive at treatment plan that is acceptable and implementable
Recommend scientifically tested and proven treatments whenever possible and appropriate to achieve treatment plan goals• Psychotherapies (CBT, IPT) and/or• Antidepressants (SSRIs)
Use common-sense approaches also• Physical exercise• Adequate nutrition
Research evidence supports use of antidepressants in adolescents with MDD• 6x more teens would benefit than would be
harmed• Significant difference between those on
medication vs on placebo• Fluoxetine has largest # of studies with
positive results• Paroxetine has largest # of studies with
negative results
When indicated by clinical presentation (clear dx of MDD w/o comorbid conditions) and patient/family preference, an SSRI should be used• Inform about adverse effects• Know potential drug interactions• Generally, effective dosages in adolescents are
lower than would be found in adult guidelines• Contact pt/family after treatment initiation to
review understanding and adherence
Patients on antidepressants will likely experience adverse effects • Routine monitoring for this is critical
Telephone vs face-to-face• Include:
Nausea Headache Possible switch to mania Behavioral activation / suicidal behavior
FDA recommendations:• “All pediatric patients should be observed
closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases
• Ideally observation face-to-face: Weekly x first 4 weeks, then Bi-weekly x 4 weeks, then At 12 weeks, then As clinically appropriate
Cognitive behavioral therapy (CBT) conducted by trained therapists for mild-to-moderate depression is effective
Few studies have been conducted on depressed adolescents undergoing interpersonal therapy (IPT)
Systematic and regular tracking of goals and outcomes of treatment should be done• Assess depressive symptoms and functioning in
Home School Peer settings
• Depressive symptoms and functional impairment may not improve at same rate
• See patient within 1 week of treatment initiation
At every visit, inquire about:• Ongoing depressive symptoms• Risk of suicide• Possible adverse effects from treatment• Adherence to treatment• New or ongoing environmental stressors
Consult mental health if teen develops psychosis, suicidal or homicidal ideation, or new/worsening comorbid conditions
Antidepressant medication should be continued for 1 year• GLAD-PC and AACAP experts conclude
medication should be maintained for 6-12 months after full resolution of depressive sx
Monitor patients monthly x 6-12 months after full resolution of symptoms• If depressive episode is a recurrence, monitor
for up to 2 years given high recurrence rate
If no improvement in 6-8 weeks, reassess:• Initial diagnosis• Choice and adequacy of initial treatment• Adherence to treatment plan• Presence of co-morbid conditions (ex:
substance abuse) or bipolar symptoms that may influence treatment effectiveness
• New external stressors
If no response to maximum therapeutic dose of antidepressant consider changing med• All SSRIs (except fluoxetine) should be slowly
tapered when discontinued (withdrawal effects) If no improvement on medication or therapy
alone add or switch to other modality After exhausting all approaches and
achieving only partial improvement consider mental health consultation
Brent DA. Antidepressants and pediatric depression--the risk of doing nothing. N Engl J Med. 2004 Oct 14;351(16):1598-601
Brent DA, Birmaher B. Clinical practice. Adolescent depression. N Engl J Med. 2002 Aug 29;347(9):667-71.
Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque D, Stein RE; GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007 Nov;120(5):e1313-26. Review. Erratum in: Pediatrics. 2008 Jan;121(1):227.
Sharp LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use in primary care settings. Am Fam Physician. 2002 Sep 15;66(6):1001-8.