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Mental Health Issues in Adolescents: Screening and Treatment Lin Sikich, MD Director, ASPIRE Program Associate Professor of Psychiatry, UNC.

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Presentation on theme: "Mental Health Issues in Adolescents: Screening and Treatment Lin Sikich, MD Director, ASPIRE Program Associate Professor of Psychiatry, UNC."— Presentation transcript:

1 Mental Health Issues in Adolescents: Screening and Treatment Lin Sikich, MD Director, ASPIRE Program Associate Professor of Psychiatry, UNC

2 Disclosures for Dr. Sikich u Research support from: u NIMH, NIH, NICHD  Eli Lilly  Janssen u Positscience  Pfizer  Bristol Meyer Squibb u Participation in industry sponsored clinical trials u ACTN  Neuropharm  Bristol Meyer Squibb u Curemark  Seaside

3 Meds w/FDA approval in adol depression u Fluoxetine (Prozac) in 8-18 yo’s with MDD u Escitalopram (Lexapro) in 12-17yo’s wMDD All other medications are used off-label for the treatment of adolescent Major Depression

4 How common is mental illness in youth? u ADHD is about 7% overall, 3% in teens u Dysthymia is about 3% in teens u Major Depression is 3% in children and ~7% in teens (equal or sl higher than adults) u One in five teens will experience major depression before they turn 20 u Bipolar disorder is ~1%

5 Prevalence of Pediatric Affective Disorders u Major Depression 1 yr Point Prevalence: children ─ 0.4 - 5 % adolescents ─ 4 - 8% Cumulative Prevalence by age 18: 15-20% u Dysthymia, 3 month point prevalence: 0.3% u Depression NOS, 3 mth point prevalence: 1.5% u Bipolar Disorder 3 month point prevalence: <0.1% Cumulative Prevalence by age 18: 0.4%-1%

6 Point Prevalence continued u Anxiety disorders are about 10% u Schizophrenia is 0.25% - 0.5% u Substance Use in past month is 8% in 8 th graders, 16% in 10 th and 22% in seniors u Alcohol 40%-58%-72% u Marijuana 6%-14%- 19%, daily1%-2.7%-5.4% u Oxycontin 2%-3.6%-4.7%

7 Potential Consequences of Depression u ↑ risk of physical illness u ↑health care costs u ↑early pregnancy u ↑substance abuse u impairments in schooling, social relationships & poorer job outcomes as adults u ↑ risk of completed suicide (8%)

8 Similar risks with other mental illnesses u 10% risk of completed suicide with bipolar disorder and with schizophrenia u Substance use increases suicide attempts by 1.4-6.2 OR u Poor health or disability increases suicide attempt by 3.0 OR

9 Copyright restrictions may apply. Libby, A. M. et al. Arch Gen Psychiatry 2009;66:633-639. But diagnosis of depression has  ’d...

10 Many affected youth are not identified u ~50% of those w/depression are not diagnosed u Only 25-30% receive any treatment u 90% of pediatricians feel they should diagnose but about ½ feel uncomfortable with their skills or that they don’t have time to fully evaluate u Schools and Primary Care Providers have become main mental health providers In 2009, USPSTF recommended routine screening for depression in primary care.

11 Accuracy of Screening tools in teens InstrumentSensitivityPositive PVNegative PV PHQ-AD735697 Beck-PC9155.698.8 Beck DI >11841099.5 CES84899 PHQ-AD free; Beck are proprietary; CES not culturally sensitive, longer with some reverse scoring

12 PHQ-Adolescent u Rates the past 2 weeks u Responses are + not at all +several days +more than ½ the days +nearly every day u MDD if any + response to mood or anhedonia and total of 5 items >50% of days u Other depressive disorder if any + response to mood or anhedonia and 2-4 items >50% of days u Takes ~ 3 min to complete Also assesses dysthymia, impairment & suicide

13 Acceptability of screening (Zuckerbrot et al, (2007), Pedatrics 119: 101-108) u 3 primary care practices screened 94% of all English speaking adolescents who came for visits while waiting for MD u Provider burden was low u Patients were felt to appreciate screening u Provider comfort dx’ing depression & screening for suicidality increased in 80% u 73% thought referrals to MHS ↑’d

14 Screening tools better than interview?

15 If the screening tool indicates depression, what to do next... u Determine severity of symptoms u Determine level of impairment u Determine if there is suicidality u Determine if there is substance abuse u R/O other disorders with similar symptoms: u Hypothyroidism  Trauma including sexual abuse u Bipolar disorder  Psychosis Must ASK directly and specifically about suicide, psychosis, substances and abuse with teen alone

16 Suicide: Risk by Diagnosis 14 12 10 8 6 4 2 0

17 Diagnosis of Bipolar Disorder Requires at least 1Manic Episode: u A distinct, qualitatively abnormal period of irritable, expansive or elevated mood AND u 3 (4 if irritable) of the following Distractibility Psychomotor Agitation Pressured Speech Racing Thoughts Grandiosity Impulsivity Decreased (< 4-6hrs) Sleep without fatigue Increased pleasurable and/or productive activities

18 Mixed Manic & Depressed Episode: Simultaneously meets criteria for both u Not a medication side effect u If irritable mood, could easily overlap u agitation, decreased sleep, poor attention u Would also need one from each class: u loss of energy, guilt, appetite change, thoughts of death u pressured speech, racing thoughts, grandiosity, excessive negative activities

19 Should assess for psychotic symptoms if: u Mood disorder u In Pediatric Depression 20-40% have hallucinations u In youth hospitalized w/mania 80% have hallucinations and 35% have 5 or more psychotic symptoms u Attentional problems don’t respond to stimulants u Multiple behavioral problems (school, isolative, aggressive) u New onset of unusual or very intense behaviors u New onset of social withdrawal u Deterioration in level of functioning or distress especially if strong family history of psychotic disorder u Probably in all substance abusers

20 Early Warning Signs of Psychosis u Increasing withdrawal u Reduction in motivation u Poor hygiene u Feeling picked on u Inattention u Becoming poorly organized u Talking under one’s breath

21 To assess for psychosis, ask... u Are there ever times when you hear something and other people act like they can’t hear it? Or times when you see something and others act like they don’t? u Are there times, when you feel really mad and don’t know why or when you feel everyone is against you? u Parents for times when child has asked if they were called and they weren’t or new onset lying about things u In teens, psychosis is equally likely to occur in affective illness as schizophrenia

22 Once you have ID’d Depression... u Ensure immediate safety: remove guns, hospitalize if needed u Develop strategies to reduce modifiable stressors (eg. school, deadlines) u If mild to moderate depression, psychotherapy alone may be effective u If severe depression, comorbid problems, suicidality or psychosis, likely will need both medication and psychotherapy u Develop a FU plan

23 Evidence treating Adolescent Depression

24 TADS Treatment Response Fig. 1: % Responders Fig. 2: No. Needed to Treat

25 CBT benefit converges in TADS

26 No benefit of adding CBT to SSRI for initial psychosocial nonresponders u British Primary Care study in 208 adolescents who had not responded to 6 session initial psychotherapy found no advantage of adding CBT Goodyer et al., 2008. Health Technology Assessment 12 (14).

27 Partners in Care Study - Asarnow u Randomly assigned 9 peds practices to usual care or quality care u Quality care involved u Team leader with depression expertise u Care manager who could do CBT u Care manager assisted with assessment, referral, both medication and psychological treatment if family & patient wished u Prior to black box warning on antidepressants

28 Improving Pediatric Depression Care (Asarnow et al., 2005 JAMA 293:311-319.) ** ** *

29 Antidepressant Potential Adverse Effects u TCA’s: sedation, constipation, weight gain sudden cardiac death, lethal in overdose u SSRI’s: u Acute side effects often mild (GI distress, dreams) u Withdrawal symptoms with short half-life agents u Reduced sexual arousal & interest u May cause activation u May lead to bipolar switch u May lead to apathy u Suicidality

30 About 4% of youth treated with antidepressants versus ~ 2% of youth treated with placebo develop significant suicidality..

31 TADS Suicidality

32 Concern about suicidality in light of questionable antidepressant efficacy u Number Needed to Treat = 9 u Number Needed to Harm = 59 Further, there are high rates of emergent suicidality with psychotherapy too. (Bridge et al., (2005) AJP 162:2173-2175) u 10/88 in CBT trial had SI during trial w/1attempt u Higher total depression scores u More cognitive distortion u More likely to have endorsed SI on Beck at w0 u 40% revealed only by self report, 60% both.

33 FDA issued black box warning for all antidepressants used in pediatric patients u Does not prohibit use of antidepressants in youth u Calls upon physicians and families to closely monitor child for u clinical worsening,  unusual behaviors  suicidality u Especially when treatment starts or dose changes u “Ideally, such observation would include: u At least weekly, face-to-face contact during 1 st 4 weeks u At least biweekly face-to-face weeks 5 through 8 u Then at week 12 and subsequently as clinically indicated u AACAP guidelines say monitoring should be individualized based on risk on specific schedule and is a partnership between MD, patient, and family

34 What if there is substance abuse? u Refer for specific substance abuse treatment u Strongly consider regular home monitoring by parents u Stress increased risk for suicide

35 What if there is psychosis? u Treat with antipsychotic u Refer for specialty mental health care u Higher risk of bipolar disorder developing u Higher risk of suicide

36 What if there is bipolar disorder u Refer for specialty mental health care u Be very cautious about use of antidepressant u Consider treatment with antipsychotic or ? Mood Stabilizer

37 Valproate is not efficacious in ped BP Placebo n=70; VPA n=74 in DB; Long-term n=54 Wagner et al., JAACAP 48:519-532, 2009.

38 Antipsychotics have efficacy in Pediatric Bipolar Disorder

39 Antipsychotic Associated Weight Gain (Correll et al, JAMA 2009; Olanzapine Quetiapine Risperidone Aripiprazole

40 Molindone Olanzapine Risperidone Mean Acute Wt ↑: 0.3 kg 6.1 kg 3.6kg Weight change varies within individuals a

41 Acute and Long-term Weight changes Weight Change, Kg P <0.008 P <0.0001

42 Potential strategies for SGA Weight Gain u More attention to healthy lifestyle instruction u Switch to lower risk agent (aripiprazole/molindone/ziprasidone) u Add an adjunctive agent like orlistat, histamine 2 blockers, amantadine or metformin, which is only agent specifically tested in youth Klein et al., AJP 2006 Placebo Metformin

43 Summary of Studies u Any youth 3-20yrs starting an antipsychotic to monitor for weight & metabolic problems u Youths 10-20yrs who have gained  10% baseline body weight on an antipsychotic to try 3 approaches to reduce weight u Treatment studies for autism and bipolar u Developmental monitoring for 3-17yo’s with autism who do NOT want medication trtmt

44 How to Refer a Patient to u Ask family if you could give their contact information to us so we can call them with more information about possible studies u Call the ASPIRE Research Hotline at: u Email us at u We will provide a comprehensive evaluation u We will facilitate care by another provider if we are not able to accept the child into a study or family chooses not to participate.

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