1. Adolescent Depression in Primary Care KAOM Annual CME Convention April 11, 2014 Debra A. Willsie, DO, FAPA, FAACAP Child-Adolescent Psychiatrist Associate Professor of Psychiatry University of Missouri-Kansas City, School of Medicine

2. Learning Objectives Upon completion participants will: –Understand the importance of screening for adolescent depression in the primary care setting. –Be aware of the normal developmental processes & changes that occur during adolescence. –Recognize the clinical signs & symptoms of Major Depressive Disorder (MDD) in adolescents & be knowledgeable of established treatment guidelines.

3. Scope of the Problem prevalence implications for health & wellbeing problems w/ early detection –PCP’s are the “front line” barriers to diagnosis obstacles in routine practice

4. Depression among Youth Major Depressive Disorder (MDD) –substantial number w/first episode –point prevalence in primary care 9 - 21% –5.6% prevalence –20 % lifetime prevalence –5 fold increase risk of suicide –8% complete suicide by young adulthood

5. Depression in Youth MDD in Adolescence –7 to 9 months –associated w/serious long-term morbidities decreased school performance increased risk substance abuse poor social functioning early pregnancy increased physical illness & higher medical care costs –recurrence rate 40 - 70% –conversion to bipolar illness 20 - 30% in subsequent 5-10 years

6. Depression in Youth MDD in Adolescence –third leading cause of death 15-24 yoa –8% of adolescent-onset complete by young adulthood Undetected suicide is critical issue in primary care –83% received health care services in the year prior to suicide –half did not have a mental health diagnosis Journal of General Internal Medicine, Feb 2014

7. Prevalence in Sub-Groups at Risk for MDD Chronic Medical Conditions –asthma 3% –celiac disease 7% –epilepsy 25% –recurrent abdominal pain 31% –obesity 33% Mental Health Conditions –ADH-D 50% –PTSD 42% –Anxiety 10-30% Parental depression 40 - 67%

9. Normal Adolescence Early Stage [10-11 yoa] –cognitive & emotional think beyond present acutely aware of their own mortality excitement of growing up yet yearn for security childhood coping with fears: defensive, irritable, secretive –need for boundaries test their environment –parents who don’t provide limits often see teenagers with excessive anxiety

10. Adolescence Early onset puberty –male viewed as stronger, more athletic –female viewed as awkward & more self conscious –follow up study @ 17 years of age [Hayward 1997] males –more popular, competent & less dependent females –less popular, submissive –@ greater risk of developing Psychiatric Disorder

12. Normal Adolescence Middle Stage [15-18 yoa] –high school years –character development learning to handle conflicting internal & external demands first serious attempt to separate from parents peer group influence yearning for close relationships but difficult to tolerate sexual impulses intensify –maladaptive feelings & impulses channeled into socially acceptable behavior

13. Middle Adolescence sublimation

15. Normal Adolescence Late Stage [18-20’s yoa] –college years –psychosocial moratorium sexually mature adolescent needs time to catch up psychologically & socially –falling in love to disenchantment intense need for sexual expression sense of loneliness –ultimate task establishing unique identity ability to make decisions, work capacity for intimacy & readiness for parenthood

16. Behavioral Patterns in Adolescence Late Stage –accidents are leading cause of death –cars & motorcycles means to satisfy inner needs & work out conflicts express anger, defiance, power, mobility and independence from adult world

18. Maladaptive behaviors Late Adolescence –illicit drug use is common escape from less than tolerable reality –suicide survey middle & high school students –33 % thoughts of – 6 % had attempted research suggests changes in child rearing & instability of home

19. Clinical Depression in Adolescents characteristics –persistent unhappiness or loss of interest –irritability (versus sadness) –sleep & appetite disturbances –complaints of fatigue, non-specific pain –behavior patterns social isolation deterioration in academics expression of anger

21. Etiology of MDD Majority have Multiple risk factors –parental depression –sub-syndromal depression –anxiety –neurobiology –temperament/personality –negative cognitions –major life event –interpersonal conflicts

22. Etiology of MDD Role of Genetics –neurochemistry + personality ability to self-regulate vulnerability creating depressogenic environment

23. NIMH Research

24. Developing Human Brain BrainSpan Atlas –incorporates gene activity or expression along w/anatomical reference atlases –neuroimaging data of mid-gestational human brain –Knowledge of where and when particular genes are expressed will facilitate research surrounding human brain development and disease

25. Genetic Markers of Suicidal Ideation Emerging During Citalopram Treatment of Major Depression Laje G, Paddock S, Manji H, Rush AJ, Wilson AF, Charney D, McMahon FJ. Am J Psychiatry. 2007 Oct; 164(10)

26. Diagnostic Criteria (DSM-5) Major Depression –five or more symptoms –at least 2 weeks: pervasive sad / irritable mood or anhedonia sleep, appetite, energy impaired concentration inappropriate guilt/ worthlessness psychomotor changes hopelessness

27. Major Depression S sleep I interest G guilt E energy C concentration A appetite P psychomotor S suicide

28. Diagnostic Criteria - DSM Dysthymia –depressed or irritable mood for one year –not without symptoms for more than 2 months –2 or more disturbances: appetite sleep energy concentration self esteem unable to make decisions hopelessness

29. Dysthymic Disorder Course - long-standing –low grade depression “Isn’t this just me and my personality?” –median duration five years can last twenty years –increases risk for MDD “double depression”

30. Diagnostic Disorders – DSM Bipolar Affective Disorder –Mania one week duration discrete period abnormal mood –elevated, grandiose or irritable 3 symptoms distractible poor concentration racing thoughts hyper-talkative flight of ideas hyper-focused on pleasure decreased need for sleep poor judgment

31. DSM- Cyclothymia Clinical Characteristics –milder, chronic form of Bipolar Disorder –characterized by hypomania dysthymia

33. Screening in primary care for Adolescent MDD Screening –is safe & reliable –efficient & not time consuming –effective in identifying –teens will disclose suicidal thoughts

34. US Preventive Services Task Force Recommendations Screening in Primary Care Settings for MDD –recommended for ages *12–18 years instruments * –PHQ-A Patient Health Questionnaire for Adolescents –73% sensitivity & specificity –BDI-PC Beck Depression Inventory – Primary Care Version –91% sensitivity & specificity *http://pediatrics.aappublications.org/content/123/4/1223.full.html

35. Treatment of Adolescent MDD

36. Antidepressants & Suicidality FDA Black Box Warning- October 2004 –warnings about increased risks of suicidal thinking and behavior = suicidality in pediatric patients –additional studies + reanalysis of FDA data no longer statistically significant for suicidal ideations Hurting or helping? –lead decrease in pharmacological treatment of pediatric depression –decrease in diagnosis of pediatric depression –seeing largest increase in teen suicide since started recording in 1979 Center for Disease Control

37. Antidepressant Use in Children, Adolescents & Adults FDA Black Warning – May, 2007 –proposed makers of all antidepressant medications –update the existing black box warning on their products' labeling –to include suicidality in young adults ages 18 to 24

38. Treatment of Adolescent Depression in the primary care setting Ambulatory Medical Care Survey –majority receive treatment 52% were prescribed antidepressant 68% were provided counseling

39. US Preventive Services Task Force Recommendations Primary Care Settings –screening tests accurately identify –benefits of detection & early intervention –efficacy in treatment SSRI’s –fluoxetine only antidepressant FDA approved –fluoxetine & citalopram yielded statistically higher response rate than others psychotherapies Screening & Treatment for Major Depressive Disorder in Children & Adolescents. Pediatrics 2009;123;1223

40. MDD in Adolescence US Preventive Services Task Force Treatment Recommendations - 2009 Medication –SSRI’s »fluoxetine only antidepressant FDA approved »fluoxetine & citalopram yielded statistically higher response rate than others Psychotherapy http://pediatrics.aappublications.org/content/123/4/1223.full.html

41. Antidepressants on market Anafranil (clomipramine) Asendin (amoxapine) Aventyl (nortriptyline) Celexa (citalopram hydrobromide) Cymbalta (duloxetine) Desyrel (trazodone HCl) Elavil (amitriptyline) Effexor (venlafaxine HCl) Emsam (selegiline) Etrafon (perphenazine/amitriptyline) fluvoxamine maleate Lexapro (escitalopram oxalate) Limbitrol (chlordiazepoxide/amitriptyline) Ludiomil (maprotiline) Marplan (isocarboxazid) Nardil (phenelzine sulfate) nefazodone HCl Norpramin (desipramine HCl) Pamelor (nortriptyline) Parnate (tranylcypromine sulfate) Paxil (paroxetine HCl) Pexeva (paroxetine mesylate) Prozac (fluoxetine HCl) Remeron (mirtazapine) Sarafem (fluoxetine HCl) Seroquel (quetiapine) Sinequan (doxepin) Surmontil (trimipramine) Symbyax (olanzapine/fluoxetine) Tofranil (imipramine) Tofranil-PM (imipramine pamoate) Triavil (perphenazine/amitriptyline) Vivactil (protriptyline) Wellbutrin (bupropion HCl) Zoloft (sertraline HCl) Zyban (bupropion HCl)

42. Suicide Prevention Resources for Teens National Suicide Prevention Lifeline –1-800-273-TALK (8255) ReachOut.com Society for the Prevention of Teen Suicide

44. Adolescence

45. Video - “Happy” by Pharell Williams http://www.youtube.com/watch?v=y6Sxv- sUYtMhttp://www.youtube.com/watch?v=y6Sxv- sUYtM

46. http://youtu.be/PKj9i1qS08M