Adolescent Depression Mary Ann Hudson, RN College of Nursing The Ohio State University

18 yo male/CC medication reconciliation following outpatient psychiatric visit Hx: 12 mo hx of major depressive disorder meeting more than five of the symptoms for MDD in DSM- IV-TR. Acute history of inpatient and outpatient treatment for MDD following medication failure and acute hypersomnia. Mat Hx of depression and anxiety. Pat Hx of depression. Co-morbidities: ADHD, inattentive type, Dx at 8 yo. Acute Hx of hypersomnia, Dx following sleep study series. Exam: HEENT, wnl; CV/Pulm, wnl; GI/GU, wnl; MS/Neuro, wnl. Affect: flat. 67”, 146#, 108/60, BMI 23

Current Diagnoses/Differentials and Plan of Care Current Diagnoses: Major Depression; ADHD, inattentive type; hypersomnia. Note: A recent meta-analysis has found that “18 percent of children diagnosed early with ADHD suffered from depression as adolescents, about 10 times the rate among those without ADHD. Children with early ADHD were five times as likely to have considered suicide at least once, and twice as likely to have made an attempt.”* Differentials (Vessey, et. al.): adjustment disorders; anxiety disorders; ADHD; eating disorders; recurrent injuries (TBI); somatic complaints; substance abuse. Plan of Care: Adderall 10mg;Buspar 30mg BID;Lithium 900mg divided 600 a.m./300 p.m.;Prozac 40mg;melatonin 9mg. Weekly CBT and additional weekly group session. * University of Chicago Medical Center (2010, October 4). Children with ADHD at increased risk for depression and suicidal thoughts as adolescents. ScienceDaily. Retrieved January 5, 2012, from /releases/2010/10/ htm

Cheung, A.H., Zuckerbrot, R.A., Jensen, P.S. (2007). Expert survey for the management of adolescent depression in primary care. Pediatrics, 1201, e101-e107. Summary: an expert survey of pediatric providers in order to consolidate typical management of depressed adolescent clients in primary care and develop the GLAD- PC guidelines for treatment. Survey was combined with current research, focus groups, and meta-analysis to create universal guidelines to manage pediatric depression clients. Results: PCP have special accountability for the management of these clients due to the shortage of mental health specialists. Guidelines should be applied and close following of these clients is best practice.

Correll, C.U. (2008). Antipsychotic use in children and adolescents: Minimizing adverse effects to maximize outcomes. Journal of the American Academy of Child and Adolescent Psychiatry, 47(1), Summary: Increasingly, adolescent pharmacological psychiatry resembles adult treatment plans. Providers still must be aware of the differing pharmacokinetics and pharmacodynamics of these medications when applied to adolescent clients. Weights or even BSA may not be accurate measures of efficacy due to rapid growth and hormonal changes that are hallmarks of this period. Results: Minimizing adverse effects relies on careful and frequent follow-up, documentation, slow and low titration, and adjunct management.

Diler, R.S., Daviss, W.B., Lopez, A. (2007). Differentiating major depressive disorders in youths with attention deficient hyperactivity disorder. Journal of Affective Disorders, 102, Summary: As ADHD clients age and respond to pharmacological treatments, it may be increasingly difficult to screen for depressive disorders due to alterations in psychomotor and sleep behaviors, especially. Results: Fewer than 1/3 of adolescents with depressive disorder are experiencing only depression. Anxiety is the most frequent co-morbidity, followed by ADHD. In differentiating ADHD from Depression, 16% of youths with ADHD ALSO had depression. Mood/anhedonia symptoms and cognitive symptoms differentiate between these diagnoses, but they are often co-current.

Trowell, L., Joffe, I., Campbell, J. (2007). Childhood depression: A place for psychotherapy. An outcome study comparing individual psychodynamic and family therapy. Journal of Child and Adolescent Psychiatry, 16, Summary: Both psychodynamic (talk) therapy and cognitive behavior therapy are equally effective in the treatment of adolescent depression and outcome studies suggest that therapy should be cocurrent to pharmacological or alternative management of adolescent depression. Results: Psychodynamic, CBT, and family therapy are all effective in the treatment and prognosis of adolescent depression and may be a primary treatment and should always be a cocurrent treatment with organic management. Therapies and pharmacological management are synergistic and behaviors learned in therapy influence functional brain chemistry.

Cheung, A.H., Zuckerbot, R.A., Jensen, P.S. (2007). Guidelines for adolescent depression in primary care (GLAD-PC: II. Treatment and ongoing management. Pediatrics, 120, e Rec #1: Screen adolescents at high risk and those with CC of mental health issues. Rec #2: Screening should include interviews with patients and their families. Rec #1 Management: Educate entire family about depression. Rec #2 Management: Create a comprehensive treatment plan that includes referral, follow-ups, education, and collaboration. Should include goals for functioning in each aspect of patient’s life. Rec #3 Management: Identify and manage referrals to support in the community. Manage and collaborate on specialist’s treatment plan. Rec #4 Mangement: Create a safety plan.

GLAD-PC.ORG for algorithm/toolkit of the AAP

Critique of Care Appropriate screening and referral was made early on for this patient, and the PCP had established a collaborative relationship with the specialist early on, including management specialist’s treatment plan. After the patient’s inpatient discharge and follow-up to primary care, a primary care treatment plan was established, including frequent visits and screening. Both the patient and the family partnered with the PCP for care. A safety plan was established that included the specialist’s emergency process. In general, though the specific toolkit algorithm was not applied, all aspect of the major recommendations were addressed in care.