Depression and Anxiety Disorders Depression and Anxiety Disorders of Children and Adolescentsof Children and Adolescents

1. Provide systematic identification of children and adolescents at risk for depressive and anxiety disorders

2. Provide a comprehensive assessment and evaluation of children and adolescents with ADHD

3. Integrate knowledge of the use of

screening tools as part of the evaluation of ADHD in children and adolescents into practice

4. Provide systematic follow-up and management to children and adolescents with depressive and anxiety disorders

Psych0therapy: treatment in which a therapist and patient(s) work together to ameliorate functional impairment through focus on the therapeutic relationship

Therapist: one who treats illness or disability

Behavioral Health Evaluation: process for screening, diagnostic, and treatment planning

Triage: a process of sorting individuals based on their need and likely benefit from immediate treatment

Follow-up visit: scheduled medical visit to evaluate ongoing status or treatment response

Active Monitoring: treatment plan that includes regular visits, supportive care, and treatment goals while awaiting specialty care

DepressionDepression: A change in mood characterized by sadness, irritability, negativity for at least two weeks

1. Sad, down, negative mood, empty feeling

2. Anhedonia

3 & 4. Changes in sleep and appetite (scored as separate symptoms)

Irritable, easily frustrated, argumentative. Focused on negative events, interprets events as negative, discounts positives. “I don’t care” attitude

Not enjoying or quitting activities (self or account by others)

May sleep, eat more or less.

5. Decreased concentration, decisiveness

6. Psychomotor agitation or retardation, observable by others

Easily swayed by others, changes mind, may question if developed ADHD, amotivation

Complaints of feeling agitated, noted pacing/ increased negative energy, or “couch potato”, amotivation

7. Complaints of fatigue

8. Feelings of worthlessness or excessive guilt

9. Death wish, Suicidal ideation, not a fear of death

Regardless of increased or decreased sleep

Negative about self, low self esteem, may feel responsible for events out of their control, discount positives and focus on negatives

May think family would be better off without them for fleeting moments or chronically, think life isn’t worth it, want to hurt self but no plan, or have a plan, and/or intent

At least 5/9 symptoms and noted dysfunction

5-6 symptoms= “mild” depression 6-7 symptoms=“moderate” depression 8-9 symptoms &/or suicidal

thoughts=“severe” Believe there is a depression but

inadequate amount of symptoms for diagnosis endorsed=“Depressive D/O NOS (not otherwise specified”

Specify single episode, recurrent, with psychotic features

Treatment Response: Period of significant decrease in symptoms or no symptoms for at least 2 weeks

Remission: Period extended 2 weeks-2 months

Recovery: Period greater than 2 months

Relapse: DSM depression reoccurs during remission

Recurrence: DSM depression occurs during recovery (new episode)

Major Depressive Disorder, recurrent, severe, with psychotic features (describes individual with 8 symptoms, second episode, and believes others are able to read their thoughts)

DysthymiaDysthymia: Sad down mood that does not fully meet criteria for depression, symptoms present for at least one year (Down mood and two other symptoms)

Irritable Appetite Change Low energy Low self esteem Difficulty making

decisions/ poor concentration

Feelings of hopelessness

Little motivation

“Reactive depression”

Overreaction to a situation as noted in mood and emotions but not fully meeting criteria for depression

If criteria is met for depression: diagnose depression

296.20 Major Depressive Disorder (MDD), unspecified (NOS)

296.21 MDD, mild 296.22 MDD, moderate 296.23 MDD, severe, without psychotic

features 296.24 MDD, severe, with psychotic

features 296.25 MDD, partial remission 296.26 MDD, in full remission Recurrent MDD, change “.2” to a “.3” for

bolded diagnosis Dysthymic D/O, 300.40 Adjustment D/O, 309.28

20% of teens will experience a clinical depression before adulthood

8% of teens suffer from depression at any one time (AACAP, 2007); adults one year point prevalence is 5.3% (Surgeon General Report, 2008)

Research: Point prevalence for adolescents with depression being seen in primary care:

GLAD-PC:II, 2007

2828%

A teen depressive episode usually lasts 8 months, or longer (8.3% will experience depression for at least one year)

40% will experience a reoccurrence of a depressive episode within 2 years, 70% before adulthood

Teens with depression have a higher incidence of STD’s, pregnancy, substance abuse, physical illness and complaints; lower rate of seeking higher education, satisfaction in relationships

30% will develop a substance abuse problem

Untreated depression is the number one cause of suicide

A depressed teen is 12 times more likely to attempt suicide

Less than 33% of teens with depression get help, but 80% could be helped with treatment

2/3 have a co-morbid condition (anxiety, dysthymia, substance abuse problem, ADHD, ODD, conduct disorder)

20% of those with a depression as a child or adolescent will eventually develop bipolar disorder. (Bipolar disorder=manic episode)

American Academy of Child and Adolescent Psychiatrists: “Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders” (2007)

American Pediatric Association: Guidelines for Adolescent Depression in Primary Care, “GLAD-PC Tool Kit” (2007)

Family history of mood disorders, depression

Past history of depression Other psychiatric disorders (anxiety,

externalizing disorders) Substance abuse Trauma Psychosocial adversity Chief complaint of emotional problem Chronic Illness

PRE-PUBERTAL CHILDREN

Increased somatic complaints

Psychomotor agitation Mood congruent

Hallucinations School refusal Phobias, separation

anxiety, increased worry

ADOLESCENTS

Irritability Apathy: “I don’t care”

attitude Low self esteem Aggression / antisocial

behavior Substance abuse Can give a reliable

and detailed history

PRE-PUBERTAL CHILDREN

1-year prevalence 0.4-2.5%

Female/ Male Ratio: 1/1

Increased risk for bipolar

ADOLESCENTS

1-year prevalence 8-9%

Female/ Male Ratio: 2/1

Screening tools, not diagnostic GLAD-PC refers to scales as “diagnostic

aids” Help to objectify significance of

symptoms Provide talking points Important to know ages and settings in

which the tools were tested Be a part of behavioral evaluations and

ongoing management

User friendly, free, takes 5-10 minutes to complete, seconds to score

Both a child and parent form A score of 20 or more is considered to

be significant for depressive symptoms, 29 or greater highly sensitive and specific for depressive disorder

Specific for depression Tested in 7-19 years including non MH

clinic patients

Tested in primary care, and extensively Child, parent, teacher forms Exclusive for depression 5-10 minutes to complete, seconds to

score Not public ($.20 per scale) Appropriate for 7-17 years Significant sore 13 or greater Has subscales to measure mood, self

esteem, ineffectiveness, anhedonia, interpersonal problems, and inconsistency index

Establish basic rules: confidentiality, when confidentiality must be broken

Interview t0gether and alone, parent before child

There are no wrong answers Not a time for discussion of treatment When do you remember being happy How long have you felt this way Beware of assumptions

OnsetLocationDuration

Characteristics (mood, thoughts, behavior)

Associated symptomsRelieving FactorsTiming

Pregnancy, birth, delivery Infancy Toddler years Preschool K-third grade 4-6 grade Junior high Senior high Include development, social, medical,

and family history, ADL’s

Determine symptom severity & progression

Frequency

Intensity

Duration

Impairment?

Completed Act: Male/Female Ratio 4:1 Attempts: Female/Male Ratio 2:1 Diagnosis of Depression (Most significant

risk factor in females) Previous suicide attempt (Most

significant risk for males) Substance Abuse Problem/ Disruptive

Behavior (two fold increase in males) Stressful life event (individual

perception) Low levels of parent-child communication

Real or media accounts of suicide (locally, intensive media coverage, fictional character): increases risk in vulnerable teens, especially young teens

Availability of lethal agents History of trauma Family history of suicidal behavior 60% of those with depression have

thought about suicide, 30% attempt (AACAP, 2001)

Death wish, suicidal thoughts, acts Any plan, organization of the plan Preoccupation with morbid or death

related music, games, art work, books, TV shows

Availability of firearms, ropes, poisons, alcohol/drugs, sharp knives

Giving away possessions Loss of rationale thought Protective factors

Appearance, behavior, attitude

Characteristics of talk

Emotional state, affective reactions

Awareness, insight, reasoning and judgement

Expansive mood, tantrums that we could not replicate in terms of energy and duration, has times with decreased need for sleep. Behaviors not specific to home.

Appear and feel energetic and overly confident, feel special, risk taker

Talk rapidly, loudly, c/o racing thoughts Work / activities completed creatively, but

disorganized Sexually preoccupied, uninhibited Decreased need for sleep (hallmark

symptom) A Change!!!!

DSM criteria: Elevated mood + 3 Irritable mood + 4

Distractibility Insomnia Grandiosity (increased pleasurable

activities)

Flight of ideas Agitation, or increased goal directed

activity Self esteem inflated Talkative (increased)

Drug and Alcohol Abuse: Depressive symptoms occur in context of use

ADHD: May occur co-morbidly with depression. Note specifics of low self esteem, concentration, amotivation

Adjustment Disorder: Question of many social pressures: if meets criteria for depression, diagnose it

Dysthymia: May occur co-morbidly with depression (rare diagnosis)

Thyroid: check growth and development family history, low thresholdAnemia (complaints of fatigue,

irritability, diet concerns): check CBCCMP: general work-up Obstructive Sleep Apnea: Noted

abnormal snoringAdverse medication reaction

(prescribed and nonprescribed)

DSM DIAGNOSIS

Relational Problem

Anxiety D/O

DEFINITION

Significant family, peer relationship issues out of context with depressive symptoms, and a need to address in treatment (Divorce, adolescent relationships)

Often co-occur, (fear that is stuck)

Identify and screen those at risk Evaluation for depression, basic

differential diagnosis, co-morbid disorders Use behavioral screens Perform risk assessment, complete a

safety plan (contract) Perform psycho-educational ,

supportive counseling Refer as needed Establish responsibilities/roles of the

provider, patient, family Schedule follow-up appointment,

goals

Identify adult(s) who are available and whom the adolescent will contact

Establish reasons to contact those adultsGive emergency numbersDetermine the adults will use the

emergency numbersEstablish a regular check in time with

the adults and health professional

Mental Illness Clear and present danger to self or

others Behavior, due to a mental illness, likely

to result in death in the near future Unwilling to sign voluntary admission Appropriate to use 911 as needed Hospital provides safety,24 hour

management

Patient: Open mind toward treatment, adhere to safety contract, honesty, healthy lifestyle changes

Family: Remain healthy, provide encouragement, follow safety contract (Consider own support)

Clinician: Follow-up every one-two weeks

Refer or treat

De-stigmatize depression Provide general facts on depression Counsel on evidence based treatment

options, need for compliance with appointments

Restore hope, past effective copers Assist with problem solving barriers to treatment Provide active listening and reflection Provide written information Case management: Contact with schools, other

health providers Recommend healthy life style Safety Contracts

Cognitive Behavioral Therapy (CBT)

Medication Only (SSRI’s)

Combination Therapy: SSRI’s and CBT

Prudent Mental Health Services in

Primary Care

Enhanced Mental Health Services In Primary Care

Treatment AsUsual: not acceptable

Level of Comfort Caution with severe depression, co-

existing conditions (previous differential diagnosis), maladaptive behaviors

Caution if roles & responsibilities (including confidentiality) of provider, family, patient can not be agreed upon

Patient &/or family desire alternative treatment that is not evidenced based practice

There is no incorrect answer, honesty is all that is needed

Parents become coaches Compliance with appointmentsParticipate /develop realistic

treatment goals

Safety Contracts

Medication management plus / minus counseling from another source

Medication management and brief psycho-therapeutic intervention

Establish goals, interventions with patient, family input (medical home model)

Reevaluate every 6-8 weeks for progress toward goals (Choose dates): scales, parent and self report

Repeat scales no more than every two weeks

Reconsider treatment plan / diagnosis if not making progress

General commitment to treatment : At least one year

Receive diagnosis and rationale, treatment options and rationale, treatment plan, treatment goals, progress toward goals

Participate in the treatment planning, goal setting

Communicate, ask about suicidal thoughts, plan, action (all members)

Activate emergency plan as needed Assist/support with any daily activities

agreed upon

Diagnosis, rationale, neurochemical theory, evidence based treatment options and rationale, pro’s and con’s of the treatment options

Participate in developing treatment goals

Open mind toward techniques / medications recommended

Practice techniques Participate in development / adhere to

safety contract

Neurological system of the body was the first “wireless” system

Thoughts activate nerve pathways, chemicals are released in response to activation

Chemicals called neurotransmitters Neurotransmitters: Serotonin &

Norepinephrine modulate mood and anxiety

Decreased supply of these chemicals=depression/anxiety

Neurochemical supply is manufactured in nerve cells and broken down by nerve cells so a fresh supply is always available

Decreased supply related to genetic factors, stress, unknown factors

Medications and specific forms of psychotherapy enhance levels of these chemicals

Medications of choice decrease the breakdown of serotonin so more of your natural chemical is available

Effectiveness has been researched extensively, and in primary care

Most effective for those who are motivated, have some insight into their mood and stressors

Require daily work (average 15 minutes)

Premise: Thoughts and behavior affect feelings, automatic thoughts

Self awareness through daily journaling: stressors, “spiral” thinking

Stressful situations that can not be changed: relax mind , body, world

Stressful situations that can be changed: problem solving

Skills have to be learned, practiced

Concept developed by Albert EllisRealized he taught the same

concepts to depressed patientsStudied and described the thought

patterns of depressed individuals

Adapted for childrenWell tested in research

Mind Reading

Forecasting

Discounting

Critical of self and others

Feelings are facts

Self blame

Interpret others actions

Decide a future event will turn out negatively

Dismiss positives, focus on negatives

Exaggerated responses

If I feel this way, then this is the way it is

Hold self responsible for events not within one’s control

Spiral Thinking Friend did not say hi to me(Internalizes, Assumes friend is mad, doesn’t ask questions, “mind reading”)

Looks sad, decreased eye contact, others avoid. Generalizes, “I have no friends” (All or nothing, critical )

I am worthless (Feelings are facts) Feels hopeless, happless, helpless to change situation

MOOD

Rate mood on scale of 1-10 Think of your worst memory=1 Think of your best memory=10 Rate mood for AM, PM, evening, overall

mood for day. Few phrases about events that effected

mood Bring to visit; if forgets, do a 24 hour recall,

ask about events for the week. If gives a couple of negative accounts, as about other days

Gives a brief overviews of the time between visits

Decreases ability to discount positives

Discovery of themes (stressors, negative thought processes)

Allow for development of intervention

Body (Diaphragmatic Breathing)

Activate the vagus nerve

Breath in, hold, out: each to the count of 4 or 5 seconds

Concentrate on the breathing

Perform 4-5 times Can be used in

combination with other techniques

Progressive Muscle Relaxation

Yoga, general exercise

Tighten Specific Muscle Groups, relax. Usually performed with the assist of a coach (CD, etc)

Imagery Visualize a safe and content memory through all the senses, picture self there. Encourage to play their own DVD in their brain

Activities that are safe, relaxing and adaptive

Question what relaxes one now, build on those skills

Examples: reading, movies, talking to friends, music, sports

Avoid video games

What is the problem (“I” terms, be specific: not acceptable to state I feel bad at school”)

Possible Solutions: Brainstorm

Pro’s and Con’s each solution, chose the one with the most positives, least negatives

Implement and Evaluate

Possible Solutions Pro’s Con’s

Result:

Dealing with guilt: Learning from mistakes= positive experience

Assertiveness training is imp0rtant part of possible solutions for problem solving

Parent Role: co-therapist if invited by child, can provide incentives for practicing skills, can practice with child, assist with journal

Aggressive

Passive or Passive-Aggressive

Assertive

“You” statements, attack others

Do or say nothing; or make up an excuse, use diversion

“I” Statements: I feel (name feeling) because (reflect observation)

Knowledge of appropriate therapy Fits well with nursing philosophy Can be performed within a 25 minute

office visit Teaching a part of CBT is helpful Does no Harm TADS, NIMH study, (2004)

demonstrated that medication plus CBT decreased suicidality, best outcome

Treatment team may choose medication as initial intervention, or if psychotherapy fails

May be only provider, or as a collaborative team member with a therapist

Accompanied at least by psycho education

Selective Serotonin Reuptake Inhibitors (SSRI’s) are first line

Fluoxetine has FDA approval for depression and OCD in children 7 years and older, positive studies for citralapram (Celexa) & Sertraline (Zoloft) published

Act over time Daily compliance is important Parents manage medication supply

SSRI Starting Dose

Increments: Every 2-4 weeks

MaximumDaily Dose: once daily

Available Doses

Fluoxetine(Prozac)FDA approval to 7 years for depression

10 mg qd 10-20 mg 60 mg in AM 10 mg tablets10, 20, 40 mg pulvules20 mg/5 cc

Sertraline(Zoloft)FDA approval to 6 years for OCD

12.5-25 mg qd 12.5-25 mg 200 mg 25, 50, 100 mg tablets

Citalopram(Celexa)

10 mg qd 10 mg 60 mg 10, 20, 40 mg tablets

Escitalopram(Lexapro)

5 mg qd 5 mg 20 mg 5, 10, 20 mg tablets

Hypomania / mania

Akathisia (physical restlessness)

Serotonin syndrome (fever, hyperthermia, restlessness, confusion)

Discontinuation syndrome (dizziness, drowsiness, nausea, lethargy, headache)

Dry Mouth Constipation/

Diarrhea Sweating Sleep Disturbance Headache Agitation or

jitteriness Appetite changes Rashes Sexual dysfunction

Disinhibition: (risk taking, impulsivity that is out of character)

Discontinuation Syndrome may be noted daily in some youth, split dose

(not a problem for Fluoxetine)

Not a cause of significant weight

Not addictive

Does not change one’s personality

Not a crutch

Start Low, Go Slow Side effects usually occur right away

with initiation or increased dose, can go away

Discontinue and see for hypo-manic symptoms

Follow guidelines by AAP for follow-up Knowledge of FDA Black Box Warning Titrate off medication slowly

Category “C” but Paroxetine (Paxil) to be moved to category “D”

Risk vs. Benefit

Emerging data noting jitteriness, mild respiratory illness, weak cry, poor muscle tone, excessive rapid respirations in infants who were exposed to SSRI use in third trimester

Based on a 2004 FDA review of reported adverse events in 23 clinical trials which involved 4,300 children & adolescents, 9 different medications

Studies used two different measures for suicidal thoughts & behavior

FDA clumped both thoughts & behavior as “suicidality”

First measure: “Event Report” Must be asked

Second measure: (17/23 studies) “Standardized Forms” questioned suicidality at each visit.

Second Measure technique considered more accepted

Studies that used event reporting noted that 2% receiving placebo expressed increased suicidality compared to 4% on medication

Studies that used standardized forms that questioned suicidality at each visit demonstrated a slight reduction in suicidality for the medication group

Significant Finding: No one in the Clinical Trials Committed Suicide!!!!!!!

FDA initially recommended weekly x 4, every two weeks x4, then in 4 weeks

AAP (GLAD-PC:II, 2007) and AACAP Practice Parameters, 2007, recommend following FDA guidelines

AACAP recommends ongoing monthly monitoring for 6 months after full remission

Follow-up can be a combination of face-to-face visits and phone contact

Increased severity of symptoms, risk factors, & suicidality increase the need for contact

Evaluation, Counsel diagnostic impression, treatment options (EBT), establish goals

Risk Assessment!!!!Safety plan. May begin treatment with

medication. Introduce journal keeping Plan next visit

Review major symptoms, treatment options, plan, current status, compliance.

Risk Assessment

Review safety plan

Review journal for mood, events, discovery of themes

Teach relaxation

Review major symptoms, plan, current status, compliance, safety plan

Repeat scales and review Review journal for mood, events,

discovery of themes Review use of relaxation, use,

effectiveness. May teach other relaxation.

Continue journal and add what makes things better

Review major symptoms, plan, current status, compliance, safety plan

Review journal for mood, events, discovery of themes

Review use of relaxation, use, effectiveness.

Teach problem solving Continue journal, add in use of

problem solving

Review major symptoms, plan, current status, compliance, safety plan

Review journal for mood, events, discovery of themes , use and effectiveness of skills

Repeat scales

Review treatment goals, plan

Maximize medication unless side effects noted

Active monitoring: increase intensity of care

Psychotherapy 6-8 weeks: Consider adding Medication

Maximized Medication Dose: Consider another medication, or adding CBT

Psychiatric Consultation if fails 1 or 2 medication trials

Always be reconsidering diagnosis

Identify youth with risk factors &/or cc of emotional problems

Establish screening processEstablish plan for systematically

screening high risk youth Establish assessment process based

on DSM IV which includes patient and family interviews

Safety evaluation (symptoms, availability of lethal items)

Provide Supportive CounselingEstablish Treatment PlanEstablish links / collaboration with

mental health resources in the community

Facilitate referralsActive monitoring: continue contact

every 1-2 weeks

Generalized Anxiety Disorder (everything)

Social Phobia (scrutiny)

Separation Anxiety Disorder

Panic disorder, with or without agoraphobia

Anxiety Disorder NOS

Psychological Factors Affecting Medical Condition (abdominal pain, headaches)

Somatoform Disorder NOS

Essential feature is excessive worry (apprehensive expectation, fear of the future) more days than not for at least 6 months

Difficult to control

In children, one of the following: c/o restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance

Essential feature is anxiety caused by exposure to a feared social situation, duration of at least 6 months

Attempt to avoid social situations, or endure at great distress

Occur in peer settings, not just with adults

Children may cry, tantrum, freeze, or shrink from the exposure

Must have the capacity for age appropriate social interaction with familiar people

Onset from preschool until 18 years of age

Duration at least 4 weeks

Developmentally inappropriate worry r/t separation from home or to whom one is attached

Three of the foll0wing are present: Distress with separation or anticipated separation, worry of harm to caretakers, worry of untoward event causing separation, physical complaints with separation or anticipated separation, repeated nightmares of separation

Disorder of prominent anxiety or phobic avoidance but does not meet criteria for specific anxiety disorder

A general medical condition is present

Stress precipitates or exacerbates the general medical condition

Stress may interfere with treatment of the medical condition

There is a close relationship between stress and increased symptoms of the medical condition

Pain in one or more anatomical sites of the body without physiological cause or general medical condition

Not intentional as in malingering or factitious disorders

Symptoms not better accounted for by a depressive or anxiety disorder

Effects 10-20% of population

Most common behavioral disorder

Often precedes depression, or occurs co-morbidly

Associated with higher levels of somatic symptoms in children and adolescents

Genetics

Environment

Trauma

Chronic Illness

Cardiac PalpitationsHyperthyroidismSeizure DisorderHypoglycemic EpisodesCaffeine AbuseMedication effect (OTC or

prescribed)Substance Abuse

Tested in 7-17 yearsResearched and found to be

effective in primary care

Child and parent form

Few minutes to scoreMeasures general, separation, social

phobia, school phobia

Preschool=predominantly separation

School age= worries decrease for separation and focus on performance

Adolescents= worries of peer acceptance

Follows Erikson’s developmental theory

Modulated by Serotonin

Effects on other neurotransmitters

Effects of long term anxiety

Everyone has fearWhat are your fearsSome your age fear….Do you have those fears everydayHow do you stop themWho do you talk to about your fears

Use OLDCART, timeline as with depression

Less research, especially in primary care Research has demonstrated effectiveness

of CBT and SSRI’s Pilot study, quasi experimental design,

demonstrated utility of 8 sessions of CBT delivered in primary care vs. treatment as usual

Study of 448 children 7-17 years demonstrated significant improvement with Sertraline and CBT over each separately, over placebo

Educate on fearFear is a healthy , keeps us safeSometimes fear gets “stuck,” that is

anxietyWE can learn to use our mind, body,

world to overcome our fearsWe then use our ”tools” to

systematically face our fears

Fear causes our body to get ready for “fight or flight”

Flight = avoidanceFight = tantrumFear effects many parts of our body

(eyes, lungs, heart, stomachAvoidance helps the moment,

strengthens the fear

THERE IS A WAY OUT!

Similar to depression (relaxation, problem solving), but include planned exposures once coping skills acquired

Patient must assist with plan development

Parents may serve a co-therapists, incentives for work on anxiety management

Is at risk for depression

Keep self and family unit healthyBe a positive role modelAssist with use of tools and

exposures as plannedProblem solve current problems,

futuristic problems = anxietyBe efficient with time before

exposure

“Flood” with exposure

Intervention for acute onset anxiety without co-morbidity (separation anxiety, school phobia)

Evaluate effectiveness in 2-3 weeks

Best practice for identification, accurate diagnosis, and treatment

Patient outcomes

Appropriate setting

Neuro-chemical etiologies, effects of treatment vs. nontreatment

Axis I (Diagnosis, focus of treatment)

Axis II (MR and personality disorders)

Axis III (Physical illnesses)

Axis IV (Psychosocial stressors)

Axis V (Global Assessment of Functioning)

Description Code Total Visit Time

Counseling Time

New patient, level 3

99203 30 minute 15.5 minutes

New patient ,level 4

99204 45 minutes 23 minutes

New patient, level 5

99205 60 minutes 30.5 minutes

Established patient,Level 3

99213 15 minutes 8 minutes

Established patient, Level 4

99214 25 minutes 13 minutes

Established patient,Level 5

99215 40 minutes 20.5 minutes

Be specific

Example: 25 minute visit with 20 minute counsel on behavioral modification, specific plan developed. Parents agree to______

Example for maintenance care: 25 minute visit with 20 minute counsel on s/s, role of medication, importance of compliance, possible s/e, treatment options and goals, usual f/u treatment rec’s. Parent and child pleased with current level due to ability to (functioning level), desire no changes. Contracts for safety, will tell Mother of any changes, dangerousness. Mother agrees to use ER, 911, or call this office as needed. Cont (med). Gave script for _________, _____refills. Mother agrees to cont. to manage med supply, oversee administration. RTC_____.

Initial Evaluation: One Hour (Level 5 based on consultation time & length of visit)

Follow-up visits: 25 minutes (Level 4) Schedule three follow-up visits per hour,

this allows for cancels and no-shows Provide minor medical evaluations, WCC

with follow-up appointments Can be reimbursed to support salary,

medical assistant, cost of rooms and overhead, psychiatric consultation up to 8 hours per month

Mental health visit, never scheduled new patient visit

PSYCHIATRIST:

Psychiatric

Evaluation, m

ed

monitorin

g,

determinatio

n of

service need,

consultatio

n,

over see

treatm

ent

plan

Psychologist:

Psychological

Evaluation, Evaluation

for intensive services,

over see treatment,

psychotherapy plans PCP’s: ID

high risk,

depressed

youth,

supportive

counseling,

active

monitoring,

assess

somatic c/o,

G&D

Counselors: Diagnostic

evaluations, psychotherapy , treatment plan

NP with MH Training: Establish systematic

plan for identification & monitoring,

comprehensive evaluation,

supportive counseling, psychoeducation,

brief focused psychotherapy,

medication management,

establish collaborative relationships, cost

effective care

Tell me, in your own words, why you are here today

Easy visit…talk, not in trouble for anything

May try to solve some problems, make something go better

Begin with social assessment Monitor family interaction Establish boundaries, expectations of

visit

NAMI, www.nami.org

Child and Adolescent Bipolar Foundation, www.bpkids.org

Depression and Bipolar Support Alliance, www.dbsalliance.org

Depression and Related Affective Disorders Association, www.drada.org

Families for Depression Awareness, www.familyaware.org

National Mental Health Association, www.nmha.org

Suicide Prevention Action Networks, www.span.org

American Academy of Child and Adolescent Psychiatry, www.aacap.org

American Academy of Pediatrics, www.aap.org

American Psychological Association, www.apa.org

Center for the Advancement of Children’s Mental Health, www.kidsmentalhealth.org

Centers for Disease Control and Prevention, www.cdc.gov

Food and Drug Administration (FDA), www.fda.gov

National Institute of Mental Health (NIMH), www.nimh.nih.gov

A parent presents with 15 year old daughter for a WCC. During the interview the Mother states her daughter suffers from depression and has been in individual therapy for 4 months and is not getting better. The therapist recommended a physical examination. The patient avoids eye contact and gives little information, she rolls her eyes as her mother talks. During the exam you notice multiple linear scars on her upper thighs, and a 20 lb weight loss since last year although BMI is WNL. How do you proceed?

Parents of a third grade male bring him to the office for complaints academic problems. He has already repeated second grade and has failing grades half way through this year. The teacher Vanderbilt has a 4/9 score for inattention, negative for hyperactivity. Parent Vanderbilt is 7/9 for inattention and 4/9 for hyperactivity. The Parent SCAReD is 29, positive for somatic complaints and school avoidance. How would you proceed?

A 5th grade female presents for c/o intermittent abd pain. Onset was the beginning of October and this is December. Previous w/u was negative. The parents note the pain occurs from Sunday evening through Friday and has resulted in much missed school, the family is about to be fined. Mother believes child’s teacher is too “loud”, yells a lot. Mother requests a medical excuse child’s absences or class changed. They called MH but can not be seen by a psychiatrist for several months. The excuse must be from a medical provider. How would you proceed?

Brent, D., Kolko, D.( 1998). Psychotherapy: Definitions, mechanisms of action, and relationship to etiological models. Journal of Abnormal Child Psychology, 26(1), 17-25.

Brent, D., Emslie, G., Clarke, G., Wagner, KD., Asarnow, JR., Keller, M., Vitiello, B., Rit,z L., Iyengar, S., Abebe, K., Birmaher, B., Ryan, N, Kennard, B., Hughes, C., DeBar, L., McCracken, J., Strober, M., Suddath, R., Spirito, A., Leonard, H., Melhem, N., Porta, G., Onorato, M., Zelazny, J. (2008). Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial, JAMA, 299(8), 901-13.

Campo, J., Shafer, S., Strohm, J., Lucas, A., Cassesse, C., Shaeffer, D., Altman, H. (2005). Pediatric behavioral health in primary care: A collaborative approach. Journal of American Psychiatric Nurses Association, 11(5), 276-282.

Cheung, A., Zuckerbrot, R., Jensen, P., Ghalib, K., Laraque, D., Stein, R. (2007). Guidelines for adolescent depression in primary care (GLAD-PC):II. Treatment and ongoing management. Pediatrics, 120, 1313-1395.

Daviss,W., Birmaher, B., Melhem, N., Axelson, D., Michaels, S., Brent, D. (2006). Criterion validity of the mood and feelings questionnaire for depressive episodes in clinic and non-clinic subjects. Journal of Child Psychology and Psychiatry, 47, 927-934.

.

Freeman, J., Garcia, A., Leonard, H. (2002). Anxiety Disorders. In Lewis, M. (Ed.), Child and Adolescent Psychiatry, (pp. 821-831). Philadelphia. Lippincott Williams & Williams.

Kovacs, M., (2003). Child’s depression inventory technical manual update (Rev ed.). North Tonawanda: Multi-Health Systems Inc.

March, J., Silvia S., Petrycki, S., Curry J., Wells K., Fairbank J., Burns B., Domino M.& McNulty S. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression, Treatment for adolescents with depression study (TADS) randomized controlled study. Journal of the American Medical Association, 292, 807-820.

Mental Health Report: A Report of the Surgeon General. (2008). Available on line at www.surgeongeneral.gov/library/mentalhealth/chapter3/sec5.html

Mental Health Report: A Report of the Surgeon General. (2008). Available on line at www.surgeongeneral.gov/library/mentalhealth/chapter3/sec6.html#autism

Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. (2007). Journal of American Academy of Child and Adolescent Psychiatry, 46:11, 1503-1526.

Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. (2007). Journal of American Academy of Child and Adolescent Psychiatry, 46:11, 107-121.

Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. (2007). Journal of American Academy of Child and Adolescent Psychiatry, 46:2, 267-279.

The use of medication in treating childhood and adolescent depression: Information for the patients and families. Available on line at ParentsMedGuide.org

Walkup, J., Albano, A., Piacentini, J., Birmaher, B., Compton, S., Sherrill, J., Ginsburg, G., Rynn, M., McCracken, J., Waslik, B., Iyengar, S., March, J., Kendall, P. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359, 1-14.

Weller, E., Weller, R., Rowan, A., Svadjian, H. (2002). Depressive disorders in children and adolescents. In Lewis M. (Ed.), Child and Adolescent Psychiatry (pp. 767-781). Philadelphia, Lippencott Williams & Williams.

Wren, F., Bridge, J., Birmaher, B. (2004). Screening for Childhood Anxiety Symptoms in Primary Care: Integrating Child and Parent Reports. Journal of American Academy of Child and Adolescent Psychiatry, 43, 1364-1370.

Zuckerbrot, R., Cheung, A., Jensen, P., Stein, R., Laraque, D. (2007). Guidelines for adolescent depression in primary care (GLAD-PC): Identification, assessment, and initial management. Pediatrics, 120, 1299-1312.