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Depression in Adolescents Part III

Depression in Adolescents Part III. Preeti Patel Matkins, MD Teen Health Connection Levine Children’s Hospital Charlotte, NC. We’ve Moved!. 2008. Depression in Adolescents. Part I Overview ”Through My Eyes” Part II Screening and Assessment Part III Treatment and Ongoing Management.

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Depression in Adolescents Part III

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  1. Depression in AdolescentsPart III Preeti Patel Matkins, MD Teen Health Connection Levine Children’s Hospital Charlotte, NC We’ve Moved! 2008

  2. Depression in Adolescents Part I Overview ”Through My Eyes” Part II Screening and Assessment Part III Treatment and Ongoing Management

  3. Depression in Adolescents Part III Treatment and ManagementGoals and Objectives By the end of this learning session, participants will be able to: -Briefly discuss diagnosis of depression -Discuss issues regarding treatment of adolescent depression; including FDA guidelines and current recommendations -Discuss ongoing management of patients being treated, medically, or nonmedically, for depression - Come up with an office based system of following patients with depression

  4. First, a review…of Part II: screening and diagnosis…

  5. National Co Morbidity Survey • Serious adult psychiatric illnesses (including MDD, AD, substance abuse) • 50% have symptoms by age 14 • 75% present by age 25 • Average time to treatment • 6-8 years for mood disorders • 9-23 years for AD • Majority of adolescent psychiatric conditions go unrecognized* • Only 50% of adolescent depression identified before adulthood • Only 25% receive adequate treatment • Parents unaware of symptoms before 90% of suicide attempts Kessler, et al. “Lifetime prevalence and age of onset of distribution of DSM-IV disorders in National Co morbidity Survey”, Archives of General Psychiatry, 2005;62:593-602. * Keesler RC et all “Mood Disorders in Children and Adolescents: An Epidemiologic Perspective”, Biol Psychiatry. 2001;49:1002-1014.

  6. Complications of Depression on Adolescents • School/College: grades, absenteeism, anxiety • Home: parents, responsibilities, withdrawal • Peers: relationships, risky behaviors • Self/Development: job/career, substance abuse, sexuality, cutting • Youths who faced depression in the last year are twice as likely to use illicit substances or alcohol for the first time National Survey on Drug Use and Health: The NDSUH Report: Depression and Initiation of alcohol and Other Drug Use among youth aged 12 to 17.

  7. Difficulty in IdentifyingDepressed Youth • Appropriate teenage behavior versus distress • Adjustment to developmental changes of puberty • Children & adolescents may have difficulty verbalizing how they are feeling • Feelings expressed as behaviors • Lack of screening

  8. Why Delay in Diagnosis and Treatment? • Recognition • Parents • Society • Providers • PCP • Unaware • Uncomfortable • Self ”treatment” • Lack of Services • FDA

  9. Pediatrician Beliefs about Adolescent Depression • 84% of pediatricians think they should be responsible for identifying depression • 53% actually inquire about depression • 20% believe that they should treat depression “ Do Pediatricians think they should care for patients with new morbidity”: AAP Periodic Survey presented at Annual Pediatric Academic Societies meeting 5/17/05 * 7000 Child and Adolescent Psychiatrists in the US (American Academy of Child and Adolescent Psychiatry)

  10. Guidelines in Adolescent Depression in Primary Care (GLAD-PC) • Clinical practice Guidelines for Primary Care Providers • North American Experts • Evidence and consensus based information • Extensive Literature Review • Target age 10-21 • GLAD-PC Toolkit www.glad-pc.org • Part I: Assessment and Diagnosis • Part II: Treatment and Ongoing Management

  11. GLAD-PC IAssessment and Diagnosis • PC Clinicians should evaluate for depression in adolescents at high risk as well as those who present with CC of emotional problems (B/very strong) • Use DSM-IV R or ICD-9 as diagnostic criteria (B/very strong) • Use standardized depression tools to aid in diagnosis (A/very strong) and combine with parent/guardian info and follow-up clinical interview

  12. DSM-IV R • Mood Episodes • MD Episode, Manic Episode, Mixed Episode, Hypomanic Episode • Mood Disorders • Depressive Disorders, Bipolar Disorders, Mood Disorder due to a General Medical Condition, Substance Induced Mood Disorder, Bereavement • NOS • Use algorithms in DSM-IV

  13. Dysthymic Disorder Less severe but more chronic than MDD • Depressed mood for most of the day for at least 2 years • *in children and adolescents • can be irritable mood • 1 year duration • 2 of the following: • poor appetite or overeating • Insomnia or hypersomnia • Fatigue or loss of energy • Low self-esteem • Poor concentration or difficulty making decisions • Hopelessness • Not other psychiatric d/o, not substance abuse

  14. Mood Disorders (DSM IV-R) Major Depressive Episode • 5 of the following have been present for 2 weeks (1) depressed mood most of the day, nearly every day in children and adolescents can be irritable mood (2) diminished interest or pleasure in most all activities most of the day (3) significant weight loss in children consider failure to gain adequate weight (4) insomnia/hypersomnia (5) psychomotor agitation or retardation (6) fatigue or loss of energy (7) feeling worthless or excessive/inappropriate guilt (8) diminished ability to think or concentrate (9) recurrent thoughts of death • Not Mixed episode • Marked change in functioning • Not due to substance use or medical condition • Not Bereavement ( or > 2 months after loss)

  15. Mood Disorders (DSM IV-R) Major Depressive Disorder • Presence of Major Depressive Episode • Not Schizoaffective Disorder, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder NOS • No History of Manic Episode, Mixed Episode, or Hypomanic Episode (unless due to medical condition) • Single vs. Recurrent

  16. Mood Disorders (DSM IV-R) • Major Depressive Disorder if the symptoms: • cause clinically significant distress or impairment in social, occupational or other areas of functioning • are not due to direct physiological effects of a substance • are not better accounted for by Bereavement

  17. Depression Part II Key Points • Depression in adolescence is common • “Risky” or “self destructive” behaviors may be self medication or coping for mental health conditions • “Depression” has many forms, and use of DSM-IV diagnostic criteria is important • There are many screening tools for depression…use them as adjunct for face to face conversation

  18. GLAD-PC Part IITreatment and Ongoing Management • Active Monitoring of Mild depression • Details of EBM medication and psychotherapeutic options in moderate to severe depression • Careful monitoring of adverse affects • Consultation and Coordination with Mental Health specialists • Ongoing evaluation • Steps to take if no improvement or worsening Cheung a, et al. “Guidelinesfor Adolescent Depression in Primary Care (GLAD-PC):II. Treatment and Ongoing Management.” Pediatrics, 2007; 120;e1313-1326.

  19. “Interventions for Adolescent Depression in Primary Care”Stein et al. Pediatrics, August 2006;18:2 • Supportive visits with PCC even without medication have a positive effect • PCC should consider MH wait time • ???Reimbursement??? • Upcoming Guidelines for Adolescent Depression in Primary Care (www.kidsmentalhealth.org) ???

  20. 3 Component Cognitive Model THOUGHTS FEELINGS BEHAVIORS • Cognitive Behavioral Therapy (CBT) • Help patient recognize and change negative patterns of thinking that contribute to depression • Interpersonal therapy (IPT) • Help individual address issues involving interpersonal relationships and conflicts that seem important in the onset or continuation of depression

  21. Cognitive behavioral techniques for primary care encountersJournal of Pediatrics, 2006; 148;567-8

  22. Cognitive behavioral techniques for primary care encountersJournal of Pediatrics, 2006; 148;567-8

  23. Cognitive behavioral techniques for primary care encountersJournal of Pediatrics, 2006; 148;567-8

  24. Treatment of Depression in Adolescents Study (TADS) (JAMA 2004; v 292,807.)

  25. TADS study had no suicides • Suicidality = thoughts of or suicidal behavior • No evidence thought  increased attempts • 23 trials of 4300 children , 4 month medication use • MDD, OCD, other dx • 9 antidepressants • Adverse events • 4% treatment vs. 2% placebo or nontreated • Not all studies asked about Suicidality at onset or at follow up • 17/23 that followed suicidality • No increase if had at beginning • No new if none at beginning • Decreased suicidality in both groups

  26. TADS study • No suicides • About 1 in 50 see some increase in suicidality • Small n trials not designed to measure suicidality • Follow up differed • More likely to overestimate associations • Association ≠ Causality ≠

  27. Timeline of SSRI Controversy Feen,P “Demystifying the Black Box Warning for Antidepressants: A protocol for safe prescribing in your practice.” Contemporary Pediatrics, V 23, No 2.

  28. Timeline of SSRI Controversy Feen,P “Demystifying the Black Box Warning for Antidepressants: A protocol for safe prescribing in your practice.” Contemporary Pediatrics, V 23, No 2.

  29. FDA “Black Box Warning” • What they said: • Monitor closely for suicidality (and other SE) in small number of children, especially early in treatment “ideally face to face” • May 2, 2007: Expand to 18-24 year olds • What they didn’t say: • Don’t use SSRI • What happened: • Decreased Treatment of Depression in children and adolescents

  30. AAP response • Remove weekly “face to face” contact: no EBM • Remove “ideally” : implies a gold standard • Remove “other psychiatric disorders”: implies OCD, anxiety also need monitoring AACAP response • Concerns about fears in families • Concerns about reluctance of PCP to care for pts

  31. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant TreatmentA Meta-analysis of Randomized Controlled TrialsBridge, et al. JAMA, V297, No 15, April 18, 2007 • Objective: assess efficacy and risk of suicidality associated with antidepressant medication for MDD, OCD, non OCD AD in children and adolescents • Data: PubMed 1998-2006, US/British reports, publications, trial registries, and author info • Background: • Treatment of Depression in Adolescents Study (TADS) (JAMA 2004) • FDA “Black Box Warning” (October 2004)

  32. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment • 27 trials (included non published) • 15 MDD, 6 OCD, 6 non OCD AD • Only meds vs. placebo (no CBT) • Grouped <12 yo; 12-18 yo • Randomized, placebo controlled parallel trials • One trial had incomplete Suicidality • 2 MDD trials without response rates • Measures varied • Average MDD trial 2 months

  33. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment • Results • SSRI efficacious for non OCD, AD, OCD, MDD • Small (1% vs. 2%) increase in suicidality • Adolescent response > children • Issues • No intention to study suicidality • Most studies screen out hi risk patients • Average only 8 weeks • Early intervention better? • Metabolism different • Compliance

  34. TADS follow-up • n = 242 Rohde P, et al. “Achievement and Maintenance of Sustained Response During the Treatment for Adolescents With Depression Study Continuation and Maintenance Therapy” Arch Gen Psychiatry. V65, No 4, April 2008

  35. TADS follow -up • CBT may • Help sustain improvement* • Avoid relapse • Avoid recurrence * Even as visits become infrequent Rohde P, et al. “Achievement and Maintenance of Sustained Response During the Treatment for Adolescents With Depression Study Continuation and Maintenance Therapy” Arch GenPsychiatry. V65, No 4, April 2008

  36. GLAD-PC Part IITreatment and Ongoing Management • Active Monitoring of Mild depression • Details of EBM medication and psychotherapeutic options in moderate to severe depression • Careful monitoring of adverse affects • Consultation and Coordination with Mental Health specialists • Ongoing evaluation • Steps to take if no improvement or worsening • GLAD-PC Toolkit Cheung a, et al. “Guidelinesfor Adolescent depression in Primary Care (GLAD-PC):II. Treatment and Ongoing Management.” Pediatrics, 2007; 120;e1313-1326.

  37. GLAD-PC IILiterature Review Psychosocial Interventions in PC • 4 articles all showed positive outcome of PC interventions • 6 articles showed 15 min counseling improved outcomes Antidepressant Treatment • Systematic review of SSRI • Clinical trials support use in adolescents • Referenced TADS • AE: 93% treatment; 73% placebo • Evidence supports routine monitoring • International studies show inverse relationship between SSRI and suicides

  38. GLAD-PC IILiterature Review • Psychotherapy: evidence supports • CBT: evidence supports • IPT: few studies, evidence supports over placebo

  39. GLAD-PC IITreatment Guidelines Recommendation 1 • After initial diagnosis, clinicians should support a period of active support and monitoring before starting other EBM treatment. ( grade of evidence: B, strength of recc: very strong) • Mild depression • Evidence that office based intervention and monitoring is effective

  40. GLAD-PC IITreatment GuidelinesRecommendation 2 • If a PC clinician identifies an adolescent with moderate or severe depression or complicating conditions such as coexisting substance abuse or psychosis, consultation with a mental health specialist should be considered. (Grade C, strength of recc: strong) • Appropriate roles and responsibilities for ongoing management by the PC and MH clinicians should be communicated and agreed upon (Grade C, strength of recc strong) • The pt and family should be consulted and approve the roles of the PC and MH professionals (Grade D, strength of recc strong)

  41. GLAD-PC IITreatment GuidelinesRecommendation 3 • PC Clinicians should recommend scientifically tested and proven treatments (i.e., psychotherapies such as CPT or IPT and/or antidepressant treatment such as SSRIs) whenever possible and appropriate to achieve the goals of the treatment plan (Grade A, strength of recc: very strong) • Use Glad-PC toolkit • Common sense approaches: exercise, nutrition • Use approved doses • Except fluoxetine (Prozac); taper slowly

  42. GLAD-PC IITreatment Guidelines Recommendation 4 • PC clinicians should monitor for the emergence of adverse events during antidepressant treatment (SSRIs). (grade of evidence: B; strength of recommendation: very strong) • There is no empirical evidence to support the requirement of weekly face-to-face meetings per se for the first 4 weeks after initiating antidepressant treatment. • In fact, evidence from large population-based surveys show high reliability of telephone interviews with adolescent subjects for the diagnosis of depression. • Attempt to follow FDA guidelines…

  43. GLAD-PC IIOngoing Management Recommendation 1 • Systematic and regular tracking of goals and outcomes from treatment should be performed, including assessment of depressive symptoms and functioning in several key domains: home, school, and peer settings. (grade of evidence: D; strength of recommendation: very strong) • patients should be seen within 1 week of the initiation of treatment • Greatest risk of relapse is in first 8-12 w after stopping medication • Continue meds for 6-12 months AFTER resolution of symptoms; monitor at least monthly

  44. GLAD-PC IIOngoing Management Recommendation 2 • Diagnosis and initial treatment should be reassessed if no improvement is noted after 6 to 8 weeks of treatment. (grade of evidence: B; strength of recommendation: very strong) • Mental health consultation should be considered. (my note: if no improvement) (grade of evidence: D; strength of recommendation: very strong)

  45. GLAD-PC IIOngoing Management Recommendation 3 • For patients who achieve only partial improvement after PC diagnostic and therapeutic approaches have been exhausted (including exploration of poor adherence, comorbid disorders, and ongoing conflicts or abuse), a mental health consultation should be considered (grade of evidence: D; strength of recommendation: very strong).

  46. GLAD-PC IIOngoing Management Recommendation 4 • PC clinicians should actively support depressed adolescents who are referred to mental health to ensure adequate management. (grade of evidence: D; strength of recommendation: very strong) • PC clinicians may also consider sharing care with mental health agencies/professionals when possible. (grade of evidence: B; strength of recommendation: very strong) • Appropriate roles and responsibilities regarding the provision and coordination of care should be communicated and agreed upon by the PC clinician and the mental health specialist. (grade of evidence: D; strength of recommendation: very strong)

  47. Initial Medication Management of MDD • SSRI • Know their dose titration • Potential Side Effects • Potential Drug Interactions • Look for drug interactions! • General goal is to pick one or two SSRIs that you feel comfortable • Prozac (fluoxetine) *EBM/FDA approved; generally first line • Paxil (paroxetine) • Zoloft (sertaline) • Celexa (citalopram) • *$4/$10 plan at Walmart and Target; others

  48. Initial Medication ManagementFluoxetine – (Prozac) • Only FDA approved SSRI for treatment of depression > 7 yo • Dosing forms: Capsules 10, 20, 40mg (liquid preparation 20mg/5ml) • Initial dose: 10 mg qday • Very Long ½ life of > 1 week in adults • Possible Titration: Can increase by 10mg qwk to max dose of 60mg/d • May take 4-6 weeks to see max benefit of a given dose • Don’t give with other seritonergic drugs because of risk of Serotonin Syndrome (esp. MAOIs and TCAs)

  49. Side Effects of SSRIs • Adverse effects of SSRIs: • Irritability, Agitation, Hostility, Impulsivity • Insomnia • Akathisia • GI-disturbance • Headache • Rash • Flu-Like Symptoms with rapid discontinuation • Worsening of Bipolar Symptoms – Hypomania/Mania/Insomnia • Sexual Dysfunction • Suicidal ideation • Panic Attacks or Increased Anxiety • Risk of Serotonin Syndrome • WEAN SLOWLY AFTER 4-6 MONTHS ( to reduce relapse) • Symptoms the FDA recommends monitoring are underlined

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