Presentation on theme: "Depression in Adolescents"— Presentation transcript:
1 Depression in Adolescents Preeti Patel Matkins, MDTeen Health ConnectionLevine Children’s HospitalCharlotte, NCWe’ve Moved!2008
2 Depression in Adolescents Part I Overview”Through My Eyes”Part II Screening and AssessmentPart III TreatmentAsk audience: What good things do you think when you have a pt with CC:depression? Bad thoughts/concerns? Then, do you like to talk/communicate with pts and families? That is the key to addressing this issue…
3 By the end of this learning session, participants will be able to: Depression in Adolescents Part II Screening and Assessment Goals and ObjectivesBy the end of this learning session, participants will be able to:To discuss why it is important to diagnose depression in adolescentsTo discuss co-morbidities of depression and how they may be related to “risky behavior”To discuss the differences between dysthymia, major depressive episode, and major depressive disorderTo discuss recommendations for screening tools for depression in children and adolescentsTo discuss strategies in interviewing families and patients about depression diagnosis
4 National Co Morbidity Survey Serious adult psychiatric illnesses(including MDD, AD, substance abuse)50% have symptoms by age 1475% present by age 25Average time to treatment6-8 years for mood disorders9-23 years for ADMajority of adolescent psychiatric conditions go unrecognized*Only 50% of adolescent depression identified before adulthoodOnly 25% receive adequate treatmentParents unaware of symptoms before 90% of suicide attemptsKessler, et al. “Lifetime prevalence and age of onset of distribution of DSM-IV disorders in National Comorbidity Survey”, Archives of General Psychiatry, 2005;62:* Keesler RC et all “Mood Disorders in Children and Adolescents: An Epidemiologic Perspective”, Biol Psychiatry. 2001;49:
5 Complications of Depression on Adolescents School/College: grades, absenteeism, anxietyHome: parents, responsibilities, withdrawalPeers: relationships, risky behaviorsSelf/Development: job/career, substance abuse, sexuality, cuttingThese can be related to MH issues/ and or cause or effect of MH issues. For last category- think ESTEEM…
6 Depression and Substance Abuse Youths who faced depression in the last year are twice as likely to use illicit substances or alcohol for the first timeFemales/Males with depression 13.3% vs 4.5% to use alcohol or illicit substance for the first time (no ethnic differences)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.First UseDepression in last yearNo DepressionAlcohol use29.2%16.5%Illicit substance16.1%6.9%Adol Females with depression more likely to use etoh than adol males.
7 2007 YRBS QuestionsDuring the past 12 months, did you ever feel so sad or hopeless almost everyday for two weeks or more in a row that you stopped doing some usual activities? Y/NDuring the past 12 months, did you ever seriously consider attempting suicide? Y/NDuring the past 12 months, did you make a plan about how you would attempt suicide? Y/NDuring the past 12 months, how many times did you actually attempt suicide? O, 1, 2 or 3, 4 or 5, 6 or moreIf you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?Youth Risk behavior Survey; q 2 years.
8 Y R B S 28.5% 14.5% 11.3% 6.9% 2% 26.9% 12.5% 9.5% 20% Not Asked 27.5% Felt sad or hopeless every day for last 2 weeks/affected behaviorSeriously Considered SuicidePlanAttempted suicide 1 or more times in the last yearAgree or strongly agree that they felt alone in their lifeTreated by a doctor or nurse2007 Overall28.5%14.5%11.3%6.9%2%NC200726.9%12.5%9.5%20%Not AskedCMS HS27.5%11.5%10.3%12.7%18%Not askedNC MS23%22%16%CMS MS21%13%Unfortunately, not asked about tx in NC, CMS. Also unfortunate that no CMS MS data on attempts, since we know many adol show sx of depression PRIOR to HS…
9 Percentage of High School Students Who Felt Sad or Hopeless, Next few slides summary of YRBS over years…Essentially, no change…This slide shows the percentage of high school students over time who had felt so sad or hopeless almost every day for two or more weeks in a row that they stopped doing some usual activities during the 12 months before the survey. During 1999 to 2007, no significant change was identified.* Almost every day for 2 or more weeks in a row so that they stopped doing some usual activities during the 12 months before the survey.1 No significant change over timeNational Youth Risk Behavior Surveys, 1999 – 2007
10 Percentage of High School Students Who Seriously Considered Attempting Suicide,* 1991 – 2007 This slide shows the percentage over time of high school students who had seriously considered attempting suicide during the 12 months before the survey. During 1991 to 2007, a significant linear decrease and a significant quadratic change were identified.* During the 12 months before the survey.1 Decreased , p < .05National Youth Risk Behavior Surveys, 1991 – 2007
11 Percentage of High School Students Who Made a Plan about How They Would Attempt Suicide,* – 2007This slide shows the percentage of high school students over time who had made a plan about how they would attempt suicide during the 12 months before the survey. During 1991 to 2007, a significant linear decrease was identified.* During the 12 months before the survey.1 Decreased , p < .05National Youth Risk Behavior Surveys, 1991 – 2007
12 Percentage of High School Students Who Attempted Suicide,* 1991 – 2007 This slide shows the percentage of high school students over time who had attempted suicide one or more times during the 12 months before the survey. During 1991 to 2007, a significant linear decrease and a significant quadratic change were identified.* One or more times during the 12 months before the survey.1 No change , decreased , p < .05National Youth Risk Behavior Surveys, 1991 – 2007
13 Percentage of High School Students Whose Suicide Attempt Resulted in an Injury, Poisoning, or an Overdose That Had To Be Treated by a Doctor or Nurse,* 1991 – 2007This slide shows the percentage of high school students over time who made a suicide attempt that resulted in an injury, poisoning, or an overdose that had to be treated by a doctor or nurse during the 12 months before the survey. During 1991 to 2007, a significant quadratic change was identified.* During the 12 months before the survey.1 No change , decreased , p < .05National Youth Risk Behavior Surveys, 1991 – 2007
14 63% of teen suicide victims exhibit psychiatric symptoms in the year prior to their death 8-25 attempts/suicideOverall males suicide 4 times greater than femalesWhy Screen adolescents and young adults? R Freidman, “Uncovering an Epidemic –Screening for Mental illness in Teens” NEJM , December 28, 2006:355:AGE (years)Male : Female Suicides10-143:115-195:120-2410:1
15 Why Delay in Diagnosis and Treatment? RecognitionParentsSocietyProvidersPCPUnawareUncomfortableSelf ”treatment”Lack of ServicesFDA
16 Pediatrician Beliefs about Adolescent Depression 84% of pediatricians think they should be responsible for identifying depression53% actually inquire about depression20% 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 5/17/05Ask audience what they think? Their concerns…
17 PC Provider IssuesTimePaperwork/documentationTraining Staff to deal with paperworkProviders ability to use and interpret screening toolsDoes Screening benefit patients?Providers comfort with families, patientsTreatment?Referral sources
18 MD Episode, Manic Episode, Mixed Episode, Hypomanic Episode DSM-IV RMood EpisodesMD Episode, Manic Episode, Mixed Episode, Hypomanic EpisodeMood DisordersDepressive Disorders, Bipolar Disorders, Mood Disorder due to a General Medical Condition, Substance Induced Mood Disorder, BereavementNOSUse algorithms in DSM-IVFirst, you have to know “what is depression”? Show DSM-IV manual and algorithm. For the prupose of this talk, I am going to stick to the most common categories.
19 Dysthymic Disorder Less severe but more chronic than MDD Depressed mood for most of the day for at least 2 years*in children and adolescentscan be irritable mood1 year duration2 of the following:poor appetite or overeatingInsomnia or hypersomniaFatigue or loss of energyLow self-esteemPoor concentration or difficulty making decisionsHopelessnessNot other psychiatric d/o, not substance abuseThis person isn’t acutely suicidal, no current plan. Kind of “eyore”..but different from just a pessimistic person.
20 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 dayin children and adolescents can be irritable mood(2) diminished interest or pleasure in most all activities most of the day(3) significant weight lossin 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 deathNot Mixed episodeMarked change in functioningNot due to substance use or medical conditionNot Bereavement ( or > 2 months after loss)
21 Mood Disorders (DSM IV-R) Major Depressive Disorder Presence of Major Depressive EpisodeNot Schizoaffective Disorder, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder NOSNo History of Manic Episode, Mixed Episode, or Hypomanic Episode (unless due to medical condition)Single vs RecurrentNotice not major depressive episode
22 Mood Disorders (DSM IV-R) Major Depressive Disorder if the symptoms:cause clinically significant distress or impairment in social, occupational or other areas of functioningare not due to direct physiological effects of a substanceare not better accounted for by Bereavement
24 Beck Depression Inventory Children’s Depression Rating Scale-revised Screening ToolsBeck Depression InventoryChildren’s Depression Rating Scale-revisedReynolds Child/Adolescent Depression Scale(lower reading level)Pediatric Symptom Checklistparent and child/adolescent version and scoringDiagnostic Predictive ScalesColumbia Health Screen/Teen ScreenCenter for Epidemiological Studies Depression Scale for Children (CES-DC) atWho has heard of screening tools? How many folks have heard of one of these? 2? More? Anyone used any of these/ What did you think? Helpful/ not?
25 Am Fam Physician review article: V 66, No 6 1001-1008 Screening ToolsMust be combined with interviewDo not addressDuration of symptomsDegree of impairmentCo morbidities (esp substance abuse in adolescents)PsychosisDo not rule out:-medical disorder (thyroid abn)-social isolation-abuse-sleep abnormalities (PTSD)Am Fam Physician review article: V 66, No
27 Beck Depression Inventory TOTAL SCORELEVELS OF DEPRESSION1-10These ups and downs are considered normal11-16Mild Mood Disturbance17-20Borderline Clinical Depression21-30Moderate Depression31-40Severe DepressionOver 40Extreme DepressionSo, really above 16, you shouldn’t be reassured without interview…and even then have to discuss with pt on why doing BDI…unless you doit on everyone…
28 Pediatric Symptom Checklist 35 items: never, sometimes, often; scoring 0, 1,2Blanks count as 0>4 blanks makes test invalidPSC: Parent Completed VersionFor 4-5 yo score >24 indicates need for further evaluationFor 6-16, score >28 indicates need for further evaluationY-PSC : For > 11yo; adolescent completesscore >30 indicates need for further evaluation
33 Do Screening Tools in Primary Care Setting Work? CompareGeneral psychosocial screeningDepression specific ScreeningChief ComplaintParent Interview and Adolescent InterviewGold Standard: Structured InterviewZuckerbrot, Rachel and Jensen, Peter “Improving Recognition of Adolescent Depression in Primary Care”Arch Pediatric Adolesc Med,160:July
34 Do Screening Tools in Primary Care Setting Work? What evidence exists for methods to identify depression in primary care?Not very muchNo studies on GAPSScreening tools alone may overestimateUsing CC only under-identifiesDepression specific does help identifyBest: Clinician training with a tool : GAPS, BDI, PARS…What identification practices are in current use?Most Primary care do not use depression specific screeningUse of self-report is rareConclusion:ID without intervention doesn’t change outcomeZuckerbrot, Rachel and Jensen, Peter “Improving Recognition of Adolescent Depression inPrimary Care” Arch Pediatric Adolesc Med,160:July
35 Do Screening Tools Work in PC Settings? Screening does improve outcome vs usual practiceBetter outcome if dialogue between PC and Mental Health ProviderAsarnow JR, Jycox LH, Duan N etal. “Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial”. JAMA. 2003;289:
36 What’s good about screening tools? USPSTF 2002Insufficient evidence to recommend use of screening tool(Does recommend for adults - Class B evidence)Using 2 questions as good as any screening tool (in adults)Over the last weeks, have you felt, down, depressed, or hopeless?Have you felt little pleasure in doing things?(Annals IM 2002 V )AAP recommends that pediatricians ask questions about depression in routine history-taking throughout adolescenceWhat’s good about screening tools?EasyStandardizedDocuments symptoms/social functioningUSPSTF. No new info since 2002…accessed
37 Guidelines for Adolescent Depression in Primary Care GLAD-PC Clinical practice guidelines for depression age 10-21Columbia NY, SUNY-Stonybrook, AAP NY Chapters 1 and 3, US Experts/specialty org/published authorsPart I: Identification, Assessment and Initial ManagementPart II: Treatment and MaintenanceZuckerbrot,RA, Cheung AH et al “Guidelines for Adolescent Depression in Primary Care (GLAD-PC)-I. Identification, Assessment and Initial Management” Pediatrics, 2007;120;e1299-e1312.
38 GLAD-PC I Identification Patients with risk factors* should be identified AND systematically monitored for development of depressive symptoms.When: WCC and other visits for at least once a yearEvidence Grade C/very strong recommendation* personal or fam hx depression, bipolar d/o, suicide related issues, substance abuse, other psychiatric disorders, significant psychosocial stressors
39 GLAD-PC I Assessment 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)
40 GLAD-PC I Assessment and Diagnosis Use of standardized depression tools Reviewed: BDI, Reynolds Adolescent Depression Screen, Mood and Feelings Questionnaire, Kutcher Adolescent Depression ScaleSensitivity 70-90%Specificity 39-90%Self alone: hi false positive and hi false negativeShould be used when combined with parent/guardian info and follow-up clinical interview
41 GLAD-PC I Assessment and Diagnosis Assessment for depression should includeDirect interviews with patient and caregiversAssessment of impairment in different domainsAssessment of other psychiatric conditionsSafety assessment(B/very strong)
42 GLAD-PC I Initial Management Clinicians shouldEducate and counsel about options (C/VS)Discuss confidentiality and limits (D/VS)Discuss management, plans, outcomes, SE (D/VS)Develop plan with families and set specific goals (C,D/VS)Establish relationships with mental health providers (C/VS) and may include families as resources (D/VS)Safety PlanNo proof safety plans change outcomeLimit access to lethal meansContact identified 3rd party/open door (C/VS)Communication if acute thoughts; esp in initial txLimit etoh/illicit substances
43 Difficulty in Identifying Depressed Youth Appropriate teenage behavior versus distressAdjustment to developmental changes of pubertyChildren & adolescents may have difficulty verbalizing how they are feelingFeelings expressed as behaviorsLack of screeningOk, so if you interview , screen, and need to re-interview…how? then what?
44 17 yo female presents with diffuse abdominal pain for the last 3 months. No vomiting, diarrhea, hematochezia, constipation, dysuria or dymenorrhea. Regular menses. LMP 2 weeks ago, last intercourse 2 months ago. Broke up with boyfriend a few weeks ago. Doing well in school, but not as well as last year. Has missed some days of school. Plays soccer, and is “OK” with her weight, but is overweight. Admits to trouble sleeping and feeling sluggish. Poor eye contact.How to ask/respond…Don’t assume “the fat girl“ is sad about weight. How do you bring up subject? What issues in hx are important? What to ask next? How sluggish? What does she do with friends- has this changed? What does she like to do now? Should you also evaluate the abdominal pain? Remember, a pt can have a physical problem and a mental health or behavioral probem.
45 Adapted from pedicases.org Observebehavior and affectresponse to questioning about depression and suicidal thoughtsMay become belligerent or sillyMay avoid questions by changing the subject or not respondingAdapted from pedicases.orgBe persistent- firm, but caring
46 Responses reflect “coping style” Motivational Interviewing techniques may be usefulBe responsive tomaladaptive copingcease discussion if mental status appears too fragileAdapted from pedicases.org
47 Difficulty in Identifying Depressed Youth HEADSSHomeEducationActivities/ExerciseDrugsSexSuicide/Esteem
48 What do you do about these things? Who do you talk to about them? Bright Futures Developmental Surveillance and School Performance assess emotional healthWhat do you do for fun?What are some of the things that worry you? Make you sad? Make you angry?What do you do about these things? Who do you talk to about them?Do you often feel sad or alone at a party?Have you ever thought about running away? Leaving home?Do you know if any of your friends or relatives have tried to hurt or kill themselves?Do you ever feel really down and depressed?Have you ever thought about hurting yourself or killing yourself?Some options…remember, be good at communication, conversation. Adol providers I know like to talk to patients!
49 Adapted from pedicases.org Assessment of psychotic featuresAre they mood congruent? :if hearing voices, are the things these voices are saying consistent/congruent with a depressed mood (e.g, “you are bad, you should die”), or are they incongruent with depressed mood (e.g., grandiose messages such as, “God has a message for you to share with the human race”)Adapted from pedicases.org
50 Need to assess psychotic features Are they mood congruent? :if hearing voices, are the things these voices are saying consistent/congruent with a depressed mood (e.g, “you are bad, you should die”)Are they incongruent with depressed mood (e.g., grandiose messages such as, “God has a message for you to share with the human race”)Neither is good!Adapted from pedicases.org
51 Warning Signs (non specific) Suicidal talkPreoccupation with death and dyingDepressionBehavioral changesGiving away possessionsArranging to take care of unfinished businessTaking excessive risksIncrease drug and/or alcohol useLoss of interest in usual activities
52 Risk Factors for Suicide in Teenagers Previous suicidal behaviorHistory of psychiatric disorder or substance abuseFamily history of suicide, psychiatric disorder or substance abuseParental loss (death or otherwise)History of abuse, violence or neglectSocial isolation/alienationPoor communication with parents, decreased family stability & family violenceStressful life events or loss
53 Factors that MAY reduce suicide risk Learned skills & problem-solvingImpulse controlConflict resolutionFamily & community supportAccess to appropriate mental health careLack of stigma for treatmentRestricted access to lethal methods of suicideCultural/religious beliefs that discourage suicide
54 Suicide Risk Assessment Do you ever have thoughts of hurting yourself in any way?Do you ever think about killing yourself?What do you think about when you think about hurting/killing yourself?How often do you think about these things?Do you think you might ever do any of these things?Is it possible that you might actually harm yourself or kill yourself?Do you have a plan?When you think about hurting yourself or killing yourself, how do you imagine you would do it?Do you think you might really do this?Are you able to get the things to enact this plan (e.g., pills, knives, guns)?What do you think it would be like if you were able to kill yourself?What would it mean to be dead (assess realistic thinking about death)?Have you ever tried to hurt yourself or kill yourself before?Have you ever known or heard of anyone who killed themselves?How close were you to this person?Adapted from pediases.orgThese are just ideas…
55 Referrals Vs. Treatment Considerations for TreatmentDepression or anxiety without suicidal ideationBest to also use CBTConsiderations for ReferralSuicidal IdeationComplicated psychosocial situationMultiple Co-morbiditiesHistory of Treatment Failures or Unusual responses to meds
56 By the end of this learning session, participants will be able to: Depression in Adolescents Part II Screening and Assessment Goals and ObjectivesBy the end of this learning session, participants will be able to:To discuss why it is important to diagnose depression in adolescentsTo discuss co-morbidities of depression and how they may be related to “risky behavior”To discuss the differences between dysthymia, major depressive episode, and major depressive disorderTo discuss recommendations for screening tools for depression in children and adolescentsTo discuss strategies in interviewing families and patients about depression diagnosis
57 Key PointsDepression 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 importantThere are many screening tools for depression…use them as adjunct for face to face conversation
58 Depression in Adolescents Part III Preeti Patel Matkins, MDTeen Health ConnectionLevine Children’s HospitalCharlotte, NCWe’ve Moved!2008
59 Depression in Adolescents Part I Overview”Through My Eyes”Part II Screening and AssessmentPart III TreatmentAsk audience: What good things do you think when you have a pt with CC:depression? Bad thoughts/concerns? Then, do you like to talk/communicate with pts and families? That is the key to addressing this issue…