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

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Presentation on theme: "Depression in Adolescents Preeti Patel Matkins, MD Teen Health Connection Levine Children’s Hospital Charlotte, NC 2008 We’ve Moved!"— Presentation transcript:

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

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

3 Depression in Adolescents Part II Screening and Assessment Goals and Objectives By the end of this learning session, participants will be able to: To discuss why it is important to diagnose depression in adolescents To discuss why it is important to diagnose depression in adolescents To discuss co-morbidities of depression and how they may be related to “risky behavior” To 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 disorder To discuss the differences between dysthymia, major depressive episode, and major depressive disorder To discuss recommendations for screening tools for depression in children and adolescents To discuss recommendations for screening tools for depression in children and adolescents To discuss strategies in interviewing families and patients about depression diagnosis To discuss strategies in interviewing families and patients about depression diagnosis

4 National Co Morbidity Survey Serious adult psychiatric illnesses Serious adult psychiatric illnesses (including MDD, AD, substance abuse) (including MDD, AD, substance abuse) 50% have symptoms by age 14 50% have symptoms by age 14 75% present by age 25 75% present by age 25 Average time to treatment Average time to treatment 6-8 years for mood disorders 6-8 years for mood disorders 9-23 years for AD 9-23 years for AD Majority of adolescent psychiatric conditions go unrecognized* Majority of adolescent psychiatric conditions go unrecognized* Only 50% of adolescent depression identified before adulthood Only 50% of adolescent depression identified before adulthood Only 25% receive adequate treatment Only 25% receive adequate treatment Parents unaware of symptoms before 90% of suicide attempts 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 Comorbidity Survey”, Archives of General Psychiatry, 2005;62: Kessler, 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: * 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, anxiety School/College: grades, absenteeism, anxiety Home: parents, responsibilities, withdrawal Home: parents, responsibilities, withdrawal Peers: relationships, risky behaviors Peers: relationships, risky behaviors Self/Development: job/career, substance abuse, sexuality, cutting Self/Development: job/career, substance abuse, sexuality, cutting

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 time Youths who faced depression in the last year are twice as likely to use illicit substances or alcohol for the first time Females/Males with depression 13.3% vs 4.5% to use alcohol or illicit substance for the first time (no ethnic differences) Females/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. 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 Use Depression in last year No Depression Alcohol use 29.2%16.5% Illicit substance 16.1%6.9%

7 2007 YRBS Questions During 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/N During 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/N During the past 12 months, did you ever seriously consider attempting suicide? Y/N During the past 12 months, did you ever seriously consider attempting suicide? Y/N During the past 12 months, did you make a plan about how you would attempt suicide? Y/N During the past 12 months, did you make a plan about how you would attempt suicide? Y/N During the past 12 months, how many times did you actually attempt suicide? O, 1, 2 or 3, 4 or 5, 6 or more During the past 12 months, how many times did you actually attempt suicide? O, 1, 2 or 3, 4 or 5, 6 or more If 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? If 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?

8 Y R B S Felt sad or hopeless every day for last 2 weeks/ affected behavior Seriously Considered Suicide Plan Attempted suicide 1 or more times in the last year Agree or strongly agree that they felt alone in their life Treated by a doctor or nurse 2007 Overall 28.5%14.5%11.3%6.9%2% NC %12.5% 9.5%11.3%20% Not Asked CMS HS %11.5%10.3%12.7%18% Not asked NC MS %22%16% Not asked CMS MS % 21%18% 13% 13% Not asked Not asked Not asked

9 Percentage of High School Students Who Felt Sad or Hopeless,* 1999 – 2007 * 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 time National Youth Risk Behavior Surveys, 1999 – 2007

10 Percentage of High School Students Who Seriously Considered Attempting Suicide,* 1991 – 2007 * During the 12 months before the survey. 1 Decreased , p <.05 National Youth Risk Behavior Surveys, 1991 – 2007

11 Percentage of High School Students Who Made a Plan about How They Would Attempt Suicide,* 1991 – 2007 * During the 12 months before the survey. 1 Decreased , p <.05 National Youth Risk Behavior Surveys, 1991 – 2007

12 Percentage of High School Students Who Attempted Suicide,* 1991 – 2007 * One or more times during the 12 months before the survey. 1 No change , decreased , p <.05 National 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 – 2007 * During the 12 months before the survey. 1 No change , decreased , p <.05 National Youth Risk Behavior Surveys, 1991 – 2007

14 Why Screen adolescents and young adults? R Freidman, “Uncovering an Epidemic –Screening for Mental illness in Teens” NEJM, December 28, 2006:355: % of teen suicide victims exhibit psychiatric symptoms in the year prior to their death 63% of teen suicide victims exhibit psychiatric symptoms in the year prior to their death 8-25 attempts/suicide 8-25 attempts/suicide Overall males suicide 4 times greater than females Overall males suicide 4 times greater than females AGE (years) Male : Female Suicides : : :1

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

16 Pediatrician Beliefs about Adolescent Depression 84% of pediatricians think they should be responsible for identifying depression 84% of pediatricians think they should be responsible for identifying depression 53% actually inquire about depression 53% actually inquire about depression 20% believe that they should treat 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 “ Do Pediatricians think they should care for patients with new morbidity”: AAP Periodic Survey presented at Annual Pediatric Academic Societies meeting 5/17/05

17 PC Provider Issues Time Time Paperwork/documentation Paperwork/documentation Training Staff to deal with paperwork Training Staff to deal with paperwork Providers ability to use and interpret screening tools Providers ability to use and interpret screening tools Does Screening benefit patients? Does Screening benefit patients? Providers comfort with families, patients Providers comfort with families, patients Treatment? Treatment? Referral sources Referral sources

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

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 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

20 Mood Disorders (DSM IV-R) Major Depressive Episode 5 of the following have been present for 2 weeks 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 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 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 Not Mixed episode Marked change in functioning Marked change in functioning Not due to substance use or medical condition Not due to substance use or medical condition Not Bereavement ( or > 2 months after loss) Not Bereavement ( or > 2 months after loss)

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

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

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24 Screening Tools Beck Depression Inventory Beck Depression Inventory Children’s Depression Rating Scale-revised Children’s Depression Rating Scale-revised Reynolds Child/Adolescent Depression Scale Reynolds Child/Adolescent Depression Scale (lower reading level) Pediatric Symptom Checklist Pediatric Symptom Checklist parent and child/adolescent version and scoring parent and child/adolescent version and scoring Diagnostic Predictive Scales Diagnostic Predictive Scales Columbia Health Screen/Teen Screen Columbia Health Screen/Teen Screen Center for Epidemiological Studies Depression Scale for Children (CES-DC) at Center for Epidemiological Studies Depression Scale for Children (CES-DC) at

25 Screening Tools Must be combined with interview Must be combined with interview Do not address Do not address Duration of symptoms Duration of symptoms Degree of impairment Degree of impairment Co morbidities (esp substance abuse in adolescents) Co morbidities (esp substance abuse in adolescents) Psychosis Psychosis Do not rule out: Do not rule out: -medical disorder (thyroid abn) -social isolation -abuse -sleep abnormalities (PTSD) Am Fam Physician review article: V 66, No

26 Beck Depression Inventory 21 topics, 0-3 Likert scale Sadness Hopelessness Life Satisfaction Suicidal Ideation Disinterest Fatigue Weight Change Attractiveness Feelings of Failure Guilt Irritability Work Ability Appetite Libido

27 Beck Depression Inventory TOTAL SCORE LEVELS OF DEPRESSION 1-10 These ups and downs are considered normal Mild Mood Disturbance Borderline Clinical Depression Moderate Depression Severe Depression Over 40 Extreme Depression

28 Pediatric Symptom Checklist 35 items: never, sometimes, often; scoring 0, 1,2 35 items: never, sometimes, often; scoring 0, 1,2 Blanks count as 0 Blanks count as 0 >4 blanks makes test invalid >4 blanks makes test invalid PSC: Parent Completed Version PSC: Parent Completed Version For 4-5 yo score >24 indicates need for further evaluation For 4-5 yo score >24 indicates need for further evaluation For 6-16, score >28 indicates need for further evaluation For 6-16, score >28 indicates need for further evaluation Y-PSC : For > 11yo; adolescent completes Y-PSC : For > 11yo; adolescent completes score >30 indicates need for further evaluation score >30 indicates need for further evaluation

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33 Do Screening Tools in Primary Care Setting Work? Compare Compare General psychosocial screening General psychosocial screening Depression specific Screening Depression specific Screening Chief Complaint Chief Complaint Parent Interview and Adolescent Interview Parent Interview and Adolescent Interview Gold Standard: Structured Interview Gold Standard: Structured Interview Zuckerbrot, 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? What evidence exists for methods to identify depression in primary care? Not very much Not very much No studies on GAPS No studies on GAPS Screening tools alone may overestimate Screening tools alone may overestimate Using CC only under-identifies Using CC only under-identifies Depression specific does help identify Depression specific does help identify Best: Clinician training with a tool : GAPS, BDI, PARS… Best: Clinician training with a tool : GAPS, BDI, PARS… What identification practices are in current use? What identification practices are in current use? Most Primary care do not use depression specific screening Most Primary care do not use depression specific screening Use of self-report is rare Use of self-report is rare Conclusion: Conclusion: ID without intervention doesn’t change outcome ID without intervention doesn’t change outcome Zuckerbrot, Rachel and Jensen, Peter “Improving Recognition of Adolescent Depression in Primary Care” Arch Pediatric Adolesc Med,160:July

35 Do Screening Tools Work in PC Settings? Screening does improve outcome vs usual practice Screening does improve outcome vs usual practice Better outcome if dialogue between PC and Mental Health Provider Better outcome if dialogue between PC and Mental Health Provider Asarnow 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 USPSTF 2002 Insufficient evidence to recommend use of screening tool Insufficient evidence to recommend use of screening tool (Does recommend for adults - Class B evidence) (Does recommend for adults - Class B evidence) Using 2 questions as good as any screening tool (in adults) Using 2 questions as good as any screening tool (in adults) Over the last weeks, have you felt, down, depressed, or hopeless? Over the last weeks, have you felt, down, depressed, or hopeless? Have you felt little pleasure in doing things? Have you felt little pleasure in doing things? (Annals IM 2002 V ) (Annals IM 2002 V ) AAP recommends that pediatricians ask questions about depression in routine history-taking throughout adolescence AAP recommends that pediatricians ask questions about depression in routine history-taking throughout adolescence What’s good about screening tools? Easy Easy Standardized Standardized Documents symptoms/social functioning Documents symptoms/social functioning

37 Guidelines for Adolescent Depression in Primary Care GLAD-PC Clinical practice guidelines for depression age Clinical practice guidelines for depression age Columbia NY, SUNY-Stonybrook, AAP NY Chapters 1 and 3, US Experts/specialty org/published authors Columbia NY, SUNY-Stonybrook, AAP NY Chapters 1 and 3, US Experts/specialty org/published authors Part I: Identification, Assessment and Initial Management Part I: Identification, Assessment and Initial Management Part II: Treatment and Maintenance Part II: Treatment and Maintenance Zuckerbrot,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. 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 year When: WCC and other visits for at least once a year Evidence Grade C/very strong recommendation Evidence 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) 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 DSM-IV R or ICD-9 as diagnostic criteria (B/very strong) Use standardized depression tools to aid in diagnosis (A/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 Scale Reviewed: BDI, Reynolds Adolescent Depression Screen, Mood and Feelings Questionnaire, Kutcher Adolescent Depression Scale Sensitivity 70-90% Sensitivity 70-90% Specificity 39-90% Specificity 39-90% Self alone: hi false positive and hi false negative Self alone: hi false positive and hi false negative Should be used when combined with parent/guardian info and follow-up clinical interview Should be used when combined with parent/guardian info and follow-up clinical interview

41 GLAD-PC I Assessment and Diagnosis Assessment for depression should include Assessment for depression should include Direct interviews with patient and caregivers Direct interviews with patient and caregivers Assessment of impairment in different domains Assessment of impairment in different domains Assessment of other psychiatric conditions Assessment of other psychiatric conditions Safety assessment Safety assessment (B/very strong)

42 GLAD-PC I Initial Management Clinicians should Clinicians should Educate and counsel about options (C/VS) Educate and counsel about options (C/VS) Discuss confidentiality and limits (D/VS) Discuss confidentiality and limits (D/VS) Discuss management, plans, outcomes, SE (D/VS) Discuss management, plans, outcomes, SE (D/VS) Develop plan with families and set specific goals (C,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) Establish relationships with mental health providers (C/VS) and may include families as resources (D/VS) Safety Plan Safety Plan No proof safety plans change outcome No proof safety plans change outcome Limit access to lethal means Limit access to lethal means Contact identified 3 rd party/open door (C/VS) Contact identified 3 rd party/open door (C/VS) Communication if acute thoughts; esp in initial tx Communication if acute thoughts; esp in initial tx Limit etoh/illicit substances Limit etoh/illicit substances

43 Difficulty in Identifying Depressed 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

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. 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… How to ask/respond…

45 Observe Observe behavior and affect behavior and affect response to questioning about depression and suicidal thoughts response to questioning about depression and suicidal thoughts May become belligerent or silly May become belligerent or silly May avoid questions by changing the subject or not responding May avoid questions by changing the subject or not responding Adapted from pedicases.org

46 Responses reflect “coping style” Responses reflect “coping style” Motivational Interviewing techniques may be useful Motivational Interviewing techniques may be useful Be responsive to Be responsive to maladaptive coping maladaptive coping cease discussion if mental status appears too fragile cease discussion if mental status appears too fragile Adapted from pedicases.org

47 HEADSS H ome H ome E ducation E ducation A ctivities/Exercise A ctivities/Exercise D rugs D rugs S ex S ex S uicide/Esteem S uicide/Esteem Difficulty in Identifying Depressed Youth

48 Bright Futures Developmental Surveillance and School Performance assess emotional health What do you do for fun? What do you do for fun? What are some of the things that worry you? Make you sad? Make you angry? 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? What do you do about these things? Who do you talk to about them? Do you often feel sad or alone at a party? Do you often feel sad or alone at a party? Have you ever thought about running away? Leaving home? 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 know if any of your friends or relatives have tried to hurt or kill themselves? Do you ever feel really down and depressed? Do you ever feel really down and depressed? Have you ever thought about hurting yourself or killing yourself? Have you ever thought about hurting yourself or killing yourself?

49 Assessment of psychotic features Assessment of 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”), 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”) 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”), 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 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”) 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! Neither is good! Adapted from pedicases.org

51 Warning Signs (non specific) Suicidal talk Preoccupation with death and dying Depression Behavioral changes Giving away possessions Arranging to take care of unfinished business Taking excessive risks Increase drug and/or alcohol use Loss of interest in usual activities

52 Risk Factors for Suicide in Teenagers Previous suicidal behavior Previous suicidal behavior History of psychiatric disorder or substance abuse History of psychiatric disorder or substance abuse Family history of suicide, psychiatric disorder or substance abuse Family history of suicide, psychiatric disorder or substance abuse Parental loss (death or otherwise) Parental loss (death or otherwise) History of abuse, violence or neglect History of abuse, violence or neglect Social isolation/alienation Social isolation/alienation Poor communication with parents, decreased family stability & family violence Stressful life events or loss

53 Factors that MAY reduce suicide risk Learned skills & problem-solving Impulse control Conflict resolution Family & community support Access to appropriate mental health care Lack of stigma for treatment Restricted access to lethal methods of suicide Cultural/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.org

55 Referrals Vs. Treatment Considerations for Treatment Considerations for Treatment Depression or anxiety without suicidal ideation Depression or anxiety without suicidal ideation Best to also use CBT Best to also use CBT Considerations for Referral Considerations for Referral Suicidal Ideation Suicidal Ideation Complicated psychosocial situation Complicated psychosocial situation Multiple Co-morbidities Multiple Co-morbidities History of Treatment Failures or Unusual responses to meds History of Treatment Failures or Unusual responses to meds

56 Depression in Adolescents Part II Screening and Assessment Goals and Objectives By the end of this learning session, participants will be able to: To discuss why it is important to diagnose depression in adolescents To discuss why it is important to diagnose depression in adolescents To discuss co-morbidities of depression and how they may be related to “risky behavior” To 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 disorder To discuss the differences between dysthymia, major depressive episode, and major depressive disorder To discuss recommendations for screening tools for depression in children and adolescents To discuss recommendations for screening tools for depression in children and adolescents To discuss strategies in interviewing families and patients about depression diagnosis To discuss strategies in interviewing families and patients about depression diagnosis

57 Key Points Depression in adolescence is common Depression in adolescence is common “Risky” or “self destructive” behaviors may be self medication or coping for mental health conditions “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 “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 There are many screening tools for depression…use them as adjunct for face to face conversation

58 Depression in Adolescents Part III Preeti Patel Matkins, MD Teen Health Connection Levine Children’s Hospital Charlotte, NC 2008 We’ve Moved!

59 Depression in Adolescents Part I Overview ”Through My Eyes” Part II Screening and Assessment Part III Treatment


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