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Depression in Adolescents

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Presentation on theme: "Depression in Adolescents"— Presentation transcript:

1 Depression in Adolescents
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 Ask 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 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 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 recommendations for screening tools for depression in children and adolescents To 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 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 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, anxiety Home: parents, responsibilities, withdrawal Peers: relationships, risky behaviors Self/Development: job/career, substance abuse, sexuality, cutting These 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 time 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. First Use Depression in last year No Depression Alcohol use 29.2% 16.5% Illicit substance 16.1% 6.9% Adol Females with depression more likely to use etoh than adol males.

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 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, 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? 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 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 2007 26.9% 12.5% 9.5% 20% Not Asked CMS HS 27.5% 11.5% 10.3% 12.7% 18% Not asked NC MS 23% 22% 16% CMS MS 21% 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 time National 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 < .05 National Youth Risk Behavior Surveys, 1991 – 2007

11 Percentage of High School Students Who Made a Plan about How They Would Attempt Suicide,* – 2007 This 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 < .05 National 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 < .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 This 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 < .05 National 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/suicide Overall males suicide 4 times greater than females Why 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 Suicides 10-14 3:1 15-19 5:1 20-24 10:1

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

16 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 Ask audience what they think? Their concerns…

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

18 MD Episode, Manic Episode, Mixed Episode, Hypomanic Episode
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 First, 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 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 This 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 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)

21 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 Notice 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 functioning are not due to direct physiological effects of a substance are not better accounted for by Bereavement

23 Everybody’s threshold is different

24 Beck Depression Inventory Children’s Depression Rating Scale-revised
Screening Tools Beck Depression Inventory Children’s Depression Rating Scale-revised Reynolds Child/Adolescent Depression Scale (lower reading level) Pediatric Symptom Checklist parent and child/adolescent version and scoring Diagnostic Predictive Scales Columbia Health Screen/Teen Screen Center for Epidemiological Studies Depression Scale for Children (CES-DC) at Who 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 Tools Must be combined with interview Do not address Duration of symptoms Degree of impairment Co morbidities (esp substance abuse in adolescents) Psychosis 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 11-16 Mild Mood Disturbance 17-20 Borderline Clinical Depression 21-30 Moderate Depression 31-40 Severe Depression Over 40 Extreme Depression So, 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, 1,2 Blanks count as 0 >4 blanks makes test invalid PSC: Parent Completed Version For 4-5 yo score >24 indicates need for further evaluation For 6-16, score >28 indicates need for further evaluation Y-PSC : For > 11yo; adolescent completes score >30 indicates need for further evaluation

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31 Answers: not at all, several days, more than half the days, mostly every day; #10 addresses function

32

33 Do Screening Tools in Primary Care Setting Work?
Compare General psychosocial screening Depression specific Screening Chief Complaint Parent Interview and Adolescent 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? Not very much No studies on GAPS Screening tools alone may overestimate Using CC only under-identifies Depression specific does help identify Best: Clinician training with a tool : GAPS, BDI, PARS… What identification practices are in current use? Most Primary care do not use depression specific screening Use of self-report is rare Conclusion: 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 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 What’s good about screening tools?
USPSTF 2002 Insufficient 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 adolescence What’s good about screening tools? Easy Standardized Documents symptoms/social functioning USPSTF. No new info since 2002…accessed

37 Guidelines for Adolescent Depression in Primary Care GLAD-PC
Clinical practice guidelines for depression age 10-21 Columbia NY, SUNY-Stonybrook, AAP NY Chapters 1 and 3, US Experts/specialty org/published authors Part I: Identification, Assessment and Initial Management 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. When: WCC and other visits for at least once a year 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) 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 Scale Sensitivity 70-90% Specificity 39-90% Self alone: hi false positive and hi false negative 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 Direct interviews with patient and caregivers Assessment of impairment in different domains Assessment of other psychiatric conditions Safety assessment (B/very strong)

42 GLAD-PC I Initial Management
Clinicians should Educate 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 Plan No proof safety plans change outcome Limit access to lethal means Contact identified 3rd party/open door (C/VS) Communication if acute thoughts; esp in initial tx 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 Ok, 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
Observe behavior and affect response to questioning about depression and suicidal thoughts May become belligerent or silly May avoid questions by changing the subject or not responding Adapted from pedicases.org Be persistent- firm, but caring

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

47 Difficulty in Identifying Depressed Youth
HEADSS Home Education Activities/Exercise Drugs Sex Suicide/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 health What 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 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”) 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 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 History of psychiatric disorder or substance abuse Family history of suicide, psychiatric disorder or substance abuse Parental loss (death or otherwise) History of abuse, violence or neglect 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 These are just ideas…

55 Referrals Vs. Treatment
Considerations for Treatment Depression or anxiety without suicidal ideation Best to also use CBT Considerations for Referral Suicidal Ideation Complicated psychosocial situation Multiple Co-morbidities History 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 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 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 recommendations for screening tools for depression in children and adolescents To discuss strategies in interviewing families and patients about depression diagnosis

57 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

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

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


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