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Learning Objectives
• To review the diagnostic criteria and clinical reality of adolescent depression
• Perform a depression assessment, based on the AAP-approved GuideLines for Adolescent Depression in Primary Care (GLAD-PC)
• Analyze two clinical case vignettes
• Use standardized questionnaires as aids in assessment of depression.
• To score and interpret standardized questionnaires applied to case vignettes
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Major Depressive Disorder in Adolescents: Common in the
Primary Care Setting
Major Depressive Disorder in Adolescents: Common in the
Primary Care Setting • Prevalence:
– Children: 2%--1:1 M:F– Adolescence: 4-8%–1:2 M:F
• Significant burden of illness on patients and families
• High rates of depression in primary care settings (Cheung et al., 2007)
• 50% of youth with depression missed in primary care settings (Chang et al., 1988, Kramer & Garralda, 1998)
• USPSTF recommends screening for depression in adolescents in primary care
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Adolescent Depression – DSM-5Adolescent Depression – DSM-5A. Five (or more) of the following symptoms for a 2-week
period and representing a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.(1) Depressed mood. Note: In children and adolescents, can be
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
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Adolescent Depression (continued)
B. The symptoms do not meet criteria for a mixed episode.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by bereavement, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
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Depression MnemonicsSig: Energy CAPs A B C D E F G H I DEAD SWAMP
Sleep Disorder Anhedonia (decreased interest in activities)
Depressed mood
Interest Deficits (anhedonia)
Bad mood Energy loss or fatigue
Guilt (feelings of worthlessness)
Concentration Anhedonia
Energy deficit Death thoughts Death thoughts
Concentration problems Energy deficits Sleep Disturbances (+/-)
Appetite changes (+ or -) Food intake changes Worthlessness of guilt
Psychomotor retardation or agitation
Guiilt/self-esteem Appetite or weight change
Suicidality Hyper/hypoactive motor behavior
Mentation (concentration) decreased
Insomnia Psychomotor agitation or retardation
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Adolescent Mood Disorders: DSM-5
• Major Depressive Disorder
• Persistent Depressive Disorder
• Depressive Disorder Unspecified
• Adjustment Disorder with Depressed Mood
• Later Units
– Bipolar Disorder – presented in Unit I
– Disruptive Mood Dysregulation Disorder – discussed in Units I & J
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Guidelines for Adolescent Depression in Primary Care (GLAD-PC):
Development Process
Guidelines for Adolescent Depression in Primary Care (GLAD-PC):
Development Process• Initial partnership between the Center for the
Advancement of Children’s Mental Health, Columbia University and University of Toronto
• Focus groups: primary care providers, parents, and youth (Toronto, and Montreal)
• Consensus Survey of PCPs, depression specialists (MD, PhD)
• Systematic Evidence based Literature Reviews
• Consensus Workshop with 80 participants
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Systematically look for patientswith depression risk factors*
*Update March 2009: US Preventive Services Task Force recommends universal SCREENING for adolescents 12-18 y.o., when systems are in place to ensure accurate diagnosis, psychotherapy (CBT), and follow-up.
GLAD-PC Guidelines: Identification/Surveillance
GLAD-PC Guidelines: Identification/Surveillance
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Depression Risk Factors
• High family loading (family history of depression)
• Stressors: – Loss, abuse, neglect, trauma, ongoing conflict and
frustrations, divorce, death (family/friend)
• Co-existing disorders (e.g., anxiety, substance abuse, ADHD, eating disorders),
• Medical illness (e.g., diabetes, asthma), • Biological and sociocultural factors
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GLAD-PC Guidelines: Assessment/Diagnosis
• PC clinicians should evaluate for depression in high-risk children or adolescents as well as those who present with emotional problems as the chief complaint.
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GLAD-PC Guidelines: Assessment/Diagnosis
• Use diagnostic criteria established in the DSM (IV, now 5)
• Use standardized depression tools
• Conduct direct interviews with the patients and families/caregivers
• Assess functional impairment
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GLAD-PC Toolkit(see www.GLADPC.org)GLAD-PC Toolkit
(see www.GLADPC.org)
• Screening and Assessment: – Screening/Assessment Tools
Columbia DISC Depression Scale (CDS)
Patient Health Questionnaire-Modified (PHQ-9)
Kutcher Adolescent Depression Scale
Beck Depression Inventory (not in toolkit)
• Administer depression screener (PHQ-9, CDS, KADS, CES-D, BDI ($), CDI ($), Other)
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How to Recognize theMoods of an Adolescent
HAPPY DEPRESSED EXCITED
ANXIOUS MANIC SUICIDAL
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Clinical Vignette – JenniferClinical Vignette – Jennifer
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Group Discussion - Jennifer
• Workbook G 1.1-1.7
• Review CDS-child. What does this score mean?
• Review CDS-parent
• Review PHQ-modified. What does the score mean?
• Review DSM-5 checklist. Does she meet DSM criteria for MDD?
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Table Activity- Jennifer
1. Review her CGAS and score it as group.
2. On the flipcharts, your scribes will write:
– CGAS score as a single number or range
– Any required lab tests
– Differential diagnoses
5 minutes!!
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Clinical Vignette – David Clinical Vignette – David
Table Activity: Using Assessment Tools
Table Activity: Using Assessment Tools
• See DAVID’s questionnaires (G 1.8 – 2.4)• Your group has 7 minutes to:
– Review David’s Columbia Depression Scale (CDS) and PHQ-M. Discuss his “scores” in the context of the vignette.
– Review David’s parental CDS. Discuss the results as they apply to the vignette and what you know about teens.
– Reconcile the scales with the vignette.– Fill out the clinician DSM checklist for David. Discuss each
criterion, in the context of the vignette, as present or absent.
– SCRIBES - Please write on your flipchart:
1. Does David meet criteria for MDD? (Y/N)
2. Differential diagnoses for David?
3. David’s CGAS score?
Copyright © The REACH Institute. All rights reserved.Unit G: Short Course Depression
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Group Discussion
• Discuss together:– What additional information do you want
before initiating the treatment planning phase?
– Lab Tests?
– ROS and further focused PE?
– Additional sources of history/functioning levels?
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Assessment Summary
• Screen all youth for depression, and carefully evaluate all screen positives, other high-risk children and youth, and those presenting with emotional problems as the chief complaint.
• Assess for depressive symptoms based on diagnostic criteria established in the DSM 5 or ICD 10; and use standardized depression tools to aid your assessment.
• Conduct face to face interviews in combination with standardized assessment tools, and use multiple sources of information ( e.g. teachers, guidance counselors) to obtain a comprehensive diagnostic picture.
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REMINDER: Please fill out Unit G
evaluation
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Getting it Paid For: Self-Study
Do you know how to code these cases so you will get paid?
Do you know when to use these coding variations?
Getting it Paid For: Self-Study
Do you know how to code these cases so you will get paid?
Do you know when to use these coding variations?
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Jennifer’s Visit: DiagnosisJennifer’s Visit: Diagnosis
Major Depressive Disorder, Single Episode, Mild: 296.21
Major Depressive Disorder. Single Episode, Unspecified: 296.2
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Jennifer’s Visit: 99215Jennifer’s Visit: 99215
Complex Medical Decision Making:– Medical Diagnosis: Extensive– Data: Extensive– Risk: High
History:– HPI: 4+– ROS: 10+– PFSH: 2
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Jennifer’s Procedures: 96110Jennifer’s Procedures: 96110 Columbia DISC Depression Scale
(CDS): Jennifer, Mother Pediatric Health Questionnaire-
Modified: Jennifer
3 standardized rating scales administered, scored and interpreted
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Jennifer’s VisitJennifer’s Visit
99215-25 (3) 96127
99215 96127 96127-59 96127-59
99215-25 96127 96127-76 96127-76
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David Visit 1: DiagnosisDavid Visit 1: Diagnosis
Major Depressive Disorder, Single Episode, Moderate: 296.22
Major Depressive Disorder, Single Episode, Unspecified: 296.2
(Other Suspected Mental Condition: V71.09)
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David’s Visit: 99215David’s Visit: 99215
Major depressive disorder meets the criteria for complex medical decision making• High risk for morbidity/mortality
• Laboratory or other diagnostic tests requiring review (rating scales)
• Extensive differential dx. to consider
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David’s Visit: 99215David’s Visit: 99215
Complex Medical Decision Making:– Medical Diagnosis: Extensive– Data: Extensive– Risk: High
History:– HPI: 4+– ROS: 10+– PFSH: 2
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David’s Visit: Prolonged Services, Too?David’s Visit: Prolonged Services, Too? Visit took 53 minutes -13 minutes
longed than the 40 minutes expected for 99215
99354: Prolonged physician service in office/out-pt. setting in excess of usual service, first hour (30-74 minutes)
No prolonged service code. (See Appendix)
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Telephone CareTelephone Care
This follow-up call would properly be considered post-service work for the visit.– Discussing results of a test directly
obtained after the encounter– Call was within 7 days of the encounter
and the next visit was within a few days of the call
– See Appendix