1. Continuity Clinic Depression

2. Continuity Clinic Objectives

3. Continuity Clinic Background Prevalence rates for depression: –1% to 2% of prepubertal children –3% to 8% of adolescents. Depression and bipolar disorder equally common in both sexes. Unipolar depressive disorders in teens more common in girls than in boys (ratio of 3:1) Early onset of puberty in girls increases the risk for depression.

4. Continuity Clinic Clinical Features & When to Consider Diagnosis Sad, irritable, or angry –may present with school or behavioral problems Somatic complaints –headache, stomachache, muscle weakness, decreased or increased appetite, fatigue, insomnia, hypersomnia, or disturbed sleep- wake cycles Self-injurious behaviors or suicidal ideation, plan, and intent

5. Continuity Clinic Identifying Risk Factors Environmental Abuse or neglect Parental substance abuse Marital problems Low socioeconomic status and education level Loss of parent, sibling, or close friend Stress related to adolescent developmental or issues of sexuality (eg, homosexuality)

6. Continuity Clinic Identifying Risk Factors Genetic Depressed parent contributes both genetic vulnerability & emotional unavailability that can contribute –combination of adverse life events and the presence of the shorter allelic form of the serotonin transporter gene results in early- onset depression Smaller prefrontal cortex and basal ganglia in depressed individuals

7. Continuity Clinic Identifying Risk Factors Medications –glucocorticoids, immunosuppressives, isotretinoin, antiviral agents Chronic illness –such as cystic fibrosis, juvenile diabetes

8. Continuity Clinic Diagnosis The Basic Steps Are symptoms present? Evaluate child’s current level of functioning relative to his or her baseline Any potential for self-injurious behavior, suicidal ideation, or suicide attempt? History taken from: –Patient –Parents –Others : teachers, counselors, or coaches.

9. Continuity Clinic Diagnosis Tools Children’s Depression Inventory (CDI) –assesses the severity of depression in prepubertal school-age children Beck Depression Inventory (BDI) Reynolds Adolescent Depression Scale (RADS-2) Mood and Feelings Questionnaire (MFQ) Adolescents

10. Continuity Clinic Diagnosis Tools The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Toolkit – Has child and parent report measures and scoring instructions on their web site http://www.thereachinstitute.org/files/documents/GLAD-PCToolkit.pdf http://www.thereachinstitute.org/files/documents/GLAD-PCToolkit.pdf –This user-friendly online resource also includes management flowcharts, scales, and educational materials in English and Spanish as well as tracking forms and information on billing

11. Continuity Clinic Treatment Pharmacological Currently, fluoxetine (Prozac)is the only antidepressant approved by the FDA in children and adolescents –research studies have demonstrated efficacy of other drugs such as citalopram, paroxetine, and sertraline Dosing of Fluoxetine –Starting at 2.5 mg/day for prepubertal children –10 mg/day for older adolescents –Most patients respond to fluoxetine at doses ranging from 20 to 80 mg/day

12. Continuity Clinic Treatment Pharmacological 2006 FDA meta-analysis of children and adolescents taking SSRIs for depression –found an increased risk of suicidality in those patients treated with drugs versus those given placebo. Subsequent meta-analysis including additional studies revealed that those who benefited from SSRI treatment outnumbered those who became suicidal during SSRI treatment by a ratio of 14:1.

13. Continuity Clinic