Depression: A Short Course. Copyright © The REACH Institute. All rights reserved. Learning...

Depression: A Short Course

http://www.thereachinstitute.org/

Copyright © The REACH Institute. All rights reserved.

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


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


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


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.


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


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


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


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


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


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.


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


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)


How to Recognize theMoods of an Adolescent

HAPPY DEPRESSED EXCITED

ANXIOUS MANIC SUICIDAL


Clinical Vignette – JenniferClinical Vignette – Jennifer


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?


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!!


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


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?


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.


REMINDER: Please fill out Unit G

evaluation


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?


Jennifer’s Visit: DiagnosisJennifer’s Visit: Diagnosis

Major Depressive Disorder, Single Episode, Mild: 296.21

Major Depressive Disorder. Single Episode, Unspecified: 296.2


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


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


Jennifer’s VisitJennifer’s Visit

99215-25 (3) 96127

99215 96127 96127-59 96127-59

99215-25 96127 96127-76 96127-76


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)


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


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


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)


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

Date post:	13-Dec-2015
Category:	Documents
Upload:	randell-flowers
View:	213 times
Download:	0 times

Depression: A Short Course. Copyright © The REACH Institute. All rights reserved. Learning...

Documents