1. Adolescent Mental Health in Primary Care: Depression
Karen Soren, M.D.
Director, Adolescent Medicine
Associate Clinical Professor
Pediatrics & Public Health
Columbia University Medical Center

2. Why is adolescent depression significant?
Epidemiology:
Point prevalence ranges from 3%-9%.
By age 18, 20% of teens have had a depressive episode.
Incidence increases with age.
Mood disorders account for the majority of adolescent suicides (which is third leading cause of death in adolescents)

3. Depression in adolescents: timing of presentation
Depression often first presents during adolescence
Susceptibility of developing brain
Sleep disturbances
Hormonal changes
Substance abuse
Psychosocial pressures

4. Depression in Adolescents: Consequences
Subsequent mood episodes, including hypomania/mania (20- 40%)
School underachievement and failure
Peer and family relationship problems
Suicide attempts, completed suicide, accidental deaths
Long-term educational and social difficulties
Substance abuse, antisocial behavior, high-risk behavior

5. Importance of Screening for Depression
The disorder is often unrecognized:
stigma
parents may not be aware of the disorder
signs may be dismissed as “typical teenager” behavior
children and teens may actively hide the disorder
Only 25-33% of depressed youths are receiving treatment for this disorder (Burns et al 1995, Leaf et al 1996)

6. Manifestations of Depression In Adolescents
withdrawal from social activities
irritability
self-criticism
low self-esteem
frequent aches and pains, somatic symptoms
tearfulness and crying

7. Manifestations of Depression In Adolescents
distinct and enduring mood / behavioral change
school problems / underachievement / failure
family conflicts
illicit substance use and abuse
suicidal crises

8. Diagnosis of Depression
The formal diagnosis for Major Depressive Disorder was conceptualized for adults.
Depression is defined by the DSM-IV as follows:
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure (see next slide):

9. Diagnosis of Depression: DSM-4
(1) depressed mood Note: In children and adolescents, this can present as irritable mood.
(2) diminished interest or pleasure in all, or almost all, activities
(3) appetite and weight changes
(4) sleep pattern disruption
(5) psychomotor agitation or retardation
(6) fatigue or loss of energy
(7) feelings of worthlessness or excessive or inappropriate guilt
(8) diminished ability to think or concentrate, or indecisiveness
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

10. Diagnosis of Depression: DSM-4
DSM-IV criteria for depression in children and adolescents are essentially similar to adults except:
Irritability can be the primary mood symptom instead of sadness in individuals under the age of 18.
Failure to meet normal expected growth milestones can be substituted for the weight loss criteria.

11. Diagnosis of Depression: DSM-4 Additional Criteria
Symptoms cause clinically significant distress/ impairment in social, occupational functioning
Symptoms not due to the direct physiological effects of a substance (drug of abuse, medication) or general medical condition (ie hypothyroidism)
Symptoms not better accounted for by bereavement (if symptoms persist > 2 mos after loss of a loved one)

12. Spectrum of Depression:
Major Depressive Disorder, Single Episode
Major Depressive Disorder, Recurrent
Dysthymic Disorder
Adjustment Disorder with Depressed Mood
Adjustment Disorder with Mixed Anxiety and Depressed Mood
Depressive Disorder Not Otherwise Specified
Bipolar Disorder
Substance-Induced Mood Disorder

13. What Causes Depression in Children and Adolescents?
Biologic correlates:
genetics, neuroendocrine, neurotransmitters, temperament, sleep abnormalities, brain anatomy/dysfunction
Psychological correlates:
dysfunctional attitudes, affect regulation problems, sexual identity issues, negative life events (loss, failure), abuse, co-morbid psychiatric disorders
Social correlates
Parental depression

14. Primary Care as Place for Identification
Extensive literature in adult primary care about identification and treatment
Integrated models show improved outcomes
Improved identification without other changes have little or no effect on outcome

15. Recommendations:
April 2009: US Preventive Services Task Force endorsed depression screening in pediatric primary care only for teens ages 12-18
No evidence of utility for screening in younger children
Adult recommendations for screening already existed as of May 2002
Screening only useful if systems in place to ensure accurate diagnosis, therapy and follow-up

16. Identification of Depression in Pediatrics/ Adolescent Medicine How is depression identified in the office setting?
Patient Interview/ Complaints
Parental Interview/ Complaints
Screening Tools

17. Patient Interview HEADSS Interview Issues:
includes depression and suicidality questions
Issues:
Do physicians have time for full interview?
Are they trained to ask these questions in a productive way?
Will adolescents be forthcoming?
Should questions be asked only at scheduled health maintenance visits, or at all visits?

18. Parental Complaints Pros: Cons:
In children, parental complaints increase the likelihood that pediatricians will identify psychosocial issues.
In adolescents, parental awareness of depression in their children will increase access to mental health services.
Cons:
Few parents are aware of their adolescent’s symptoms (Logan and King, 2002)
Adolescents may arrive without their parents.

19. Screening Instruments
Pros:
Increased identification possible
Universal screening possible, recommended by some
Time efficient in waiting room
May increase adolescent disclosure of symptoms

20. Screening Instruments
Cons:
Time consuming to screen all
Burdon on system
Many instruments available – how do you choose (PHQ-A, Becks)
False-positives possible
Improved outcomes depend on proper follow-up of positive screens

21. The Diagnostic Process
Best if collateral information collected (from parent, school, etc)
Positive screens/questions should be followed up:
Suicidality must be addressed
Safety issues – may need to send to Emergency Room

22. The Diagnostic Process
Co-morbidity is the rule, not the exception
Depression frequently co-occurs with anxiety disorders, ADHD, oppositional defiant disorder, conduct disorder, substance abuse, etc.
Must rule-out bipolar disorder

23. Confidentiality Issues in Depression and Suicide Screening
Legality of breaking confidentiality varies by state
Must break confidentiality when teen is danger to self or others
Clinician needs to judge when parental involvement is beneficial or harmful

24. Treatment Issues in Pediatric And Adolescent Depression
Who needs treatment?
Treat persistent depression
Treat dysfunction
Determine if watchful waiting is appropriate
Reassess the patient in 2-4 weeks from the initial evaluation to determine persistence

25. TADS-Treatment for Adolescents with Depression Study (JAMA, 2004)
439 patients with depression (MDD) at 13 US academic or community centers
RCT of effects of four 12-wk treatments (fluoxetine alone, CBT alone, CBT plus fluoxetine, and placebo)
Placebo and fluoxetine administered double-blinded
Results: Response to fluoxetine plus CBT (71%) better than placebo (35%) or either modality alone (fluoxetine-61% and CBT-43%)
Results: Fluoxetine alone better than CBT alone
Results: Clinically significant suicidal thinking (present in 29% of sample at baseline) improved in all 4 treatment groups
1.6% sample attempted suicide (no completed suicides)

26. TADS – After 36 weeks
Treated placebo group after week 12 but excluded them from analysis
Rates of response: 85%- combination therapy, 69% -fluoxetine therapy, and 65% for CBT at week 18
Rates of response: 86% -combination therapy, 81%- fluoxetine therapy, and 81% -CBT at week 36
Suicidal ideation decreased with treatment, but less so with fluoxetine therapy than with combination therapy or CBT.
Suicidal events -more common in fluoxetine therapy (14.7%) than combination therapy (8.4%) or CBT (6.3%).
CONCLUSIONS: In adolescents with moderate to severe depression, treatment with fluoxetine alone or in combination with CBT accelerates response. Adding CBT to medication enhances safety of medication.
Taking benefits and harms into account, combined treatment appears superior to either monotherapy

27. Cognitive Behavioral Therapy
Principle of CBT is that thoughts influence behaviors and feelings, and vice versa.
Treatment targets patient’s thoughts and behaviors to improve his/her mood.
Essential elements of CBT include increasing pleasurable activities (behavioral activation), reducing negative thoughts (cognitive restructuring), and improving assertiveness and problem-solving skills to reduce feelings of hopelessness.

28. Interpersonal Therapy-Adolescent
Principle of IPT-A is that interpersonal problems may cause or exacerbate depression and that depression, in turn, may exacerbate interpersonal problems. Treatment will target patient’s interpersonal problems to improve both interpersonal functioning and his/her mood.
Essential elements of interpersonal therapy include identifying an interpersonal problem area, improving interpersonal problem-solving skills, and modifying communication patterns.

29. Medications: Antidepressants
SSRI’s are the current medications of choice for treatment of depression
Fluoxetine was the only FDA-approved choice for depression in children and adolescents
Since 2004, the FDA has requested a warning (Black Box Warning) on all antidepressants, including tricyclics and SSRI’s, for both young adults and children, about increased risk of suicidality
More recently, Lexapro (escitalopram) also approved for youth ages for treatment of major depression
Fluvoxamine (also an SSRI) approved for treatment of OCD in children and adults

30. Medication Information SSRI’s
Generally safe (must be aware of FDA warning)
Common side effects: GI disturbance, changes in appetite, sleep disturbance, sexual dysfunction
Agitation possible initially
Usual duration of medication treatment - 6 months to 1 year after symptoms improve

31. Medication Information SSRI’s
Side effects - serious
serotonin syndrome (fever, nausea, confusion, hyperthermia, restlessness, etc.)
akathisia
precipitation of mania
anaphylaxis
discontinuation syndrome (dizziness, drowsiness, nausea, lethargy, headache)

32. Medication Information SSRI’s
Recent FDA warning regarding suicide and SSRI’s: How can it be understood?
Discontinuation issue? (Is it only in patients who skip doses or stop abruptly?)
Suicide as an aspect of depression/anxiety? (Was the difference from the placebo group a failure of randomization?)
Akathasia left untreated? (Did patients complain?)
If true/real, then how about the recent study showing a decrease in suicide rates in areas of increased SSRI’s prescriptions?

33. Medication Information SSRI’s- First Line
Starting Dose
Increments
Max Daily
Dose
Contra-
Indicated
Medications
Available
Doses
Fluoxetine
(Prozac)
FDA: MDD/OCD
10 mg qd
10-20 mg per dose
60 mg
MAOIs
10,20,40 mg
90 mg weekly
(Liquid too)
Escitalopram
(Lexapro)
FDA: MDD
10 mg per dose
30 mg
10 mg
Paroxetine
(Paxil)
FDA safety warning
10,20,30,40 mg (liquid too)
Sertraline
(Zoloft)
FDA: OCD
25 mg qd
mg per dose
200 mg
25,50,100
mg (liquid too)
Citalopram
(Celexa)

34. Medication Information Second Line Antidepressants: (Consult Psychiatrist)
Starting
Dose
Increments
Max Daily Dose
Side
Effects
Contra-
indicated
Meds
Available
Doses
Bupropion
(Wellbutrin
SR)
No studies showing efficacy in children
100 mg QD
mg per dose
400 mg
Seizures, GI, rashes, HAs, sleep
MAOIs
100, 150,
200 mg
-this is SR
Venlafaxine
(Effexor XR)
Wyeth has warned not to use in children
37.5 mg QD
37.5 mg per dose
300 mg
Increased BP, GI, rashes, HAs, CV effects
MAOIs, pressors (e.g., stimulants, asthma meds)
37.5, mg

35. Monitoring of children and adolescents on SSRIs:
USPSTF recommends judicious monitoring of all patients started on antidepressants because of the risk of adverse events (primarily suicidality)
AAP encourages use of rating scales for diagnosis of depression at baseline and during treatment
Need to regularly monitor efficacy and adverse effects once patient starts meds
Telephone vs face-to-face monitoring depends on patient situation
Particular need to monitor during drug initiation, titration and discontinuation periods

36. References
Screening and Treatment for Major Depressive Disorder in Children and Adolescents: US Preventive Services Task Force. Pediatrics 2009; 123:
Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the US Preventative Task Force. Williams et al. Pediatrics 2009; 123:
Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA Aug 18;292(7):
The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. March, Silva et al. Arch Gen Psychiatry Oct;64(10):