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Depression in Adolescents
Preeti Patel Matkins, MDTeen Health Connection
Levine Children’s HospitalCharlotte, NC
2008
We’ve Moved!
Depression in Adolescents
Part I Overview”Through My Eyes”
Part II Screening and Assessment
Part III Treatment
Depression in Adolescents Part II Screening and Assessment
Goals and Objectives
By the end of this learning session, participants will be able to:
To discuss why it is important to diagnose depression in adolescents
To discuss co-morbidities of depression and how they may be related to “risky behavior”
To discuss the differences between dysthymia, major depressive episode, and major depressive disorder
To discuss recommendations for screening tools for depression in children and adolescents
To discuss strategies in interviewing families and patients about depression diagnosis
National Co Morbidity Survey Serious adult psychiatric illnesses (including MDD, AD, substance abuse)
50% have symptoms by age 14 75% present by age 25
Average time to treatment 6-8 years for mood disorders 9-23 years for AD
Majority of adolescent psychiatric conditions go unrecognized* Only 50% of adolescent depression identified before
adulthood Only 25% receive adequate treatment
Parents unaware of symptoms before 90% of suicide attempts
Kessler, et al. “Lifetime prevalence and age of onset of distribution of DSM-IV disorders in National Comorbidity Survey”, Archives of General Psychiatry, 2005;62:593-602.
* Keesler RC et all “Mood Disorders in Children and Adolescents: An Epidemiologic Perspective”, Biol Psychiatry. 2001;49:1002-1014.
Complications of Depression on Adolescents
School/College: grades, absenteeism, anxiety
Home: parents, responsibilities, withdrawal
Peers: relationships, risky behaviors
Self/Development: job/career, substance abuse, sexuality, cutting
Depression and Substance Abuse
Youths who faced depression in the last year are twice as likely to use illicit substances or alcohol for the first time
Females/Males with depression 13.3% vs 4.5% to use alcohol or illicit substance for the first time (no ethnic differences)
National Survey on Drug Use and Health: The NDSUH Report: Depression and Initiation of alcohol and Other Drug Use among youth aged 12 to 17.
First Use Depression in last year
No Depression
Alcohol use 29.2% 16.5%
Illicit substance
16.1% 6.9%
2007 YRBS Questions
During the past 12 months, did you ever feel so sad or hopeless almost everyday for two weeks or more in a row that you stopped doing some usual activities? Y/N
During the past 12 months, did you ever seriously consider attempting suicide? Y/N
During the past 12 months, did you make a plan about how you would attempt suicide? Y/N
During the past 12 months, how many times did you actually attempt suicide? O, 1, 2 or 3, 4 or 5, 6 or more
If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?
Y R B S
Felt sad or hopeless every day for last 2 weeks/affected behavior
Seriously Considered Suicide
Plan Attempted suicide 1 or more times in the last year
Agree or strongly agree that they felt alone in their life
Treated by a doctor or nurse
2007 Overall
28.5% 14.5% 11.3% 6.9% 2%
NC 2007
26.9% 12.5%
9.5% 11.3% 20% Not Asked
CMS HS2007
27.5% 11.5% 10.3% 12.7% 18% Not asked
NC MS2007
23% 22% 16% Not asked Not asked Not asked
CMS MS2007
21% 18% 13% Not asked
Not asked
Not asked
Percentage of High School Students Who Felt Sad or Hopeless,* 1999 – 2007
* Almost every day for 2 or more weeks in a row so that they stopped doing some usual activities during the 12 months before the survey.1 No significant change over time
National Youth Risk Behavior Surveys, 1999 – 2007
28.3 28.3 28.5128.528.6
0
20
40
60
80
100
1999 2001 2003 2005 2007
Percent
Percentage of High School Students Who Seriously Considered Attempting Suicide,*
1991 – 2007
* During the 12 months before the survey.1 Decreased 1991-2007, p < .05
National Youth Risk Behavior Surveys, 1991 – 2007
29.024.1 24.1
20.5 19.314.5116.916.919.0
0
20
40
60
80
100
1991 1993 1995 1997 1999 2001 2003 2005 2007
Percent
Percentage of High School Students Who Made a Plan about How They Would Attempt
Suicide,* 1991 – 2007
* During the 12 months before the survey.1 Decreased 1991-2007, p < .05
National Youth Risk Behavior Surveys, 1991 – 2007
18.6 19.0 17.7 15.7 14.511.3113.0
16.514.8
0
20
40
60
80
100
1991 1993 1995 1997 1999 2001 2003 2005 2007
Percent
Percentage of High School Students Who Attempted Suicide,* 1991 – 2007
* One or more times during the 12 months before the survey.1 No change 1991-2001, decreased 2001-2007, p < .05
National Youth Risk Behavior Surveys, 1991 – 2007
7.3 8.6 8.7 7.7 8.3 6.918.48.58.8
0
20
40
60
80
100
1991 1993 1995 1997 1999 2001 2003 2005 2007
Percent
Percentage of High School Students Whose Suicide Attempt Resulted in an Injury,
Poisoning, or an Overdose That Had To Be Treated by a Doctor or Nurse,* 1991 – 2007
* During the 12 months before the survey.1 No change 1991-2003, decreased 2003-2007, p < .05
National Youth Risk Behavior Surveys, 1991 – 2007
1.7 2.7 2.8 2.6 2.6 2.012.32.92.6
0
20
40
60
80
100
1991 1993 1995 1997 1999 2001 2003 2005 2007
Percent
Why Screen adolescents and young adults?
R Freidman, “Uncovering an Epidemic –Screening for Mental illness in Teens” NEJM , December 28, 2006:355:2717-9.
63% of teen suicide victims exhibit psychiatric symptoms in the year prior to their death
8-25 attempts/suicide
Overall males suicide 4 times greater than females
AGE (years) Male : Female Suicides
10-14 3:1
15-19 5:1
20-24 10:1
Why Delay in Diagnosis and Treatment?
Recognition Parents Society Providers
PCP Unaware Uncomfortable
Self ”treatment” Lack of Services FDA
Pediatrician Beliefs about Adolescent Depression
84% of pediatricians think they should be responsible for identifying depression
53% actually inquire about depression
20% believe that they should treat depression
“ Do Pediatricians think they should care for patients with new morbidity”: AAP Periodic Survey presented at Annual Pediatric Academic Societies meeting 5/17/05
PC Provider Issues
Time Paperwork/documentation Training Staff to deal with paperwork Providers ability to use and interpret screening
tools Does Screening benefit patients?
Providers comfort with families, patients Treatment? Referral sources
DSM-IV R
Mood Episodes MD Episode, Manic Episode, Mixed Episode,
Hypomanic Episode Mood Disorders
Depressive Disorders, Bipolar Disorders, Mood Disorder due to a General Medical Condition, Substance Induced Mood Disorder, Bereavement
NOS Use algorithms in DSM-IV
Dysthymic Disorder Less severe but more chronic than MDD
Depressed mood for most of the day for at least 2 years *in children and adolescents
can be irritable mood 1 year duration
2 of the following: poor appetite or overeating Insomnia or hypersomnia Fatigue or loss of energy Low self-esteem Poor concentration or difficulty making decisions Hopelessness
Not other psychiatric d/o, not substance abuse
Mood Disorders (DSM IV-R) Major Depressive Episode
5 of the following have been present for 2 weeks (1) depressed mood most of the day, nearly every day in children and adolescents can be irritable mood(2) diminished interest or pleasure in most all activities most of the day (3) significant weight loss in children consider failure to gain adequate weight(4) insomnia/hypersomnia (5) psychomotor agitation or retardation (6) fatigue or loss of energy (7) feeling worthless or excessive/inappropriate guilt (8) diminished ability to think or concentrate (9) recurrent thoughts of death
Not Mixed episode Marked change in functioning Not due to substance use or medical condition Not Bereavement ( or > 2 months after loss)
Mood Disorders (DSM IV-R) Major Depressive Disorder
Presence of Major Depressive Episode Not Schizoaffective Disorder, Schizophreniform
Disorder, Delusional Disorder, or Psychotic Disorder NOS
No History of Manic Episode, Mixed Episode, or Hypomanic Episode (unless due to medical condition)
Single vs Recurrent
Mood Disorders (DSM IV-R)
Major Depressive Disorder if the symptoms:
cause clinically significant distress or impairment in social, occupational or other areas of functioning
are not due to direct physiological effects of a substance
are not better accounted for by Bereavement
Screening Tools
Beck Depression Inventory Children’s Depression Rating Scale-revised Reynolds Child/Adolescent Depression Scale
(lower reading level) Pediatric Symptom Checklist
parent and child/adolescent version and scoring Diagnostic Predictive Scales Columbia Health Screen/Teen Screen Center for Epidemiological Studies Depression Scale
for Children (CES-DC) at www.brightfutures.org
Screening Tools
Must be combined with interview Do not address
Duration of symptoms Degree of impairment Co morbidities (esp substance abuse in adolescents) Psychosis Do not rule out:
-medical disorder (thyroid abn)-social isolation-abuse-sleep abnormalities (PTSD)Am Fam Physician review article: V 66, No 6 1001-1008
Beck Depression Inventory21 topics, 0-3 Likert scale
Sadness Hopelessness Life Satisfaction Suicidal Ideation Disinterest Fatigue Weight Change
Attractiveness Feelings of Failure Guilt Irritability Work Ability Appetite Libido
Beck Depression Inventory
TOTAL SCORE LEVELS OF DEPRESSION
1-10 These ups and downs are considered normal
11-16 Mild Mood Disturbance
17-20 Borderline Clinical Depression
21-30 Moderate Depression
31-40 Severe Depression
Over 40 Extreme Depression
Pediatric Symptom Checklist
35 items: never, sometimes, often; scoring 0, 1,2 Blanks count as 0 >4 blanks makes test invalid
PSC: Parent Completed Version For 4-5 yo score >24 indicates need for further evaluation For 6-16, score >28 indicates need for further evaluation
Y-PSC : For > 11yo; adolescent completes score >30 indicates need for further evaluation
Do Screening Tools in Primary Care Setting Work?
Compare General psychosocial screening Depression specific Screening Chief Complaint Parent Interview and Adolescent Interview
Gold Standard: Structured Interview
Zuckerbrot, Rachel and Jensen, Peter “Improving Recognition of Adolescent Depression in Primary Care”Arch Pediatric Adolesc Med,160:July 2006 694-704.
Do Screening Tools in Primary Care Setting Work?
What evidence exists for methods to identify depression in primary care? Not very much No studies on GAPS Screening tools alone may overestimate Using CC only under-identifies Depression specific does help identify Best: Clinician training with a tool : GAPS, BDI, PARS…
What identification practices are in current use? Most Primary care do not use depression specific screening Use of self-report is rare
Conclusion: ID without intervention doesn’t change outcome
Zuckerbrot, Rachel and Jensen, Peter “Improving Recognition of Adolescent Depression inPrimary Care” Arch Pediatric Adolesc Med,160:July 2006 694-704.
Do Screening Tools Work in PC Settings?
Screening does improve outcome vs usual practice
Better outcome if dialogue between PC and Mental Health Provider
Asarnow JR, Jycox LH, Duan N etal. “Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial”. JAMA. 2003;289:3145-3151.
USPSTF 2002
Insufficient evidence to recommend use of screening tool (Does recommend for adults - Class B evidence) Using 2 questions as good as any screening tool (in adults)
Over the last weeks, have you felt, down, depressed, or hopeless? Have you felt little pleasure in doing things? (Annals IM 2002 V136 760-4)
AAP recommends that pediatricians ask questions about depression in routine history-taking throughout adolescence
What’s good about screening tools? Easy Standardized Documents symptoms/social functioning
Guidelines for Adolescent Depression in Primary Care GLAD-PC
Clinical practice guidelines for depression age 10-21
Columbia NY, SUNY-Stonybrook, AAP NY Chapters 1 and 3, US Experts/specialty org/published authors
Part I: Identification, Assessment and Initial Management
Part II: Treatment and Maintenance
Zuckerbrot,RA, Cheung AH et al “Guidelines for Adolescent Depression in Primary Care (GLAD-PC)-I. Identification, Assessment and Initial Management” Pediatrics, 2007;120;e1299-e1312.
GLAD-PC IIdentification
Patients with risk factors* should be identified AND systematically monitored for development of depressive symptoms.
When: WCC and other visits for at least once a year
Evidence Grade C/very strong recommendation
* personal or fam hx depression, bipolar d/o, suicide related issues, substance abuse, other psychiatric disorders, significant psychosocial stressors
GLAD-PC IAssessment and Diagnosis
PC Clinicians should evaluate for depression in adolescents at high risk as well as those who present with CC of emotional problems (B/very strong)
Use DSM-IV R or ICD-9 as diagnostic criteria (B/very strong)
Use standardized depression tools to aid in diagnosis (A/very strong)
GLAD-PC IAssessment and Diagnosis
Use of standardized depression tools
Reviewed: BDI, Reynolds Adolescent Depression Screen, Mood and Feelings Questionnaire, Kutcher Adolescent Depression Scale
Sensitivity 70-90% Specificity 39-90% Self alone: hi false positive and hi false negative
Should be used when combined with parent/guardian info and follow-up clinical interview
GLAD-PC IAssessment and Diagnosis
Assessment for depression should include Direct interviews with patient and caregivers Assessment of impairment in different domains Assessment of other psychiatric conditions Safety assessment
(B/very strong)
GLAD-PC IInitial Management
Clinicians should Educate and counsel about options (C/VS)
Discuss confidentiality and limits (D/VS)
Discuss management, plans, outcomes, SE (D/VS)
Develop plan with families and set specific goals (C,D/VS)
Establish relationships with mental health providers (C/VS) and may include families as resources (D/VS)
Safety Plan No proof safety plans change outcome Limit access to lethal means Contact identified 3rd party/open door (C/VS) Communication if acute thoughts; esp in initial tx Limit etoh/illicit substances
Difficulty in IdentifyingDepressed Youth
Appropriate teenage behavior versus distress
Adjustment to developmental changes of puberty
Children & adolescents may have difficulty verbalizing how they are feeling
Feelings expressed as behaviors Lack of screening
17 yo female presents with diffuse abdominal pain for the last 3 months. No vomiting, diarrhea, hematochezia, constipation, dysuria or dymenorrhea. Regular menses. LMP 2 weeks ago, last intercourse 2 months ago. Broke up with boyfriend a few weeks ago. Doing well in school, but not as well as last year. Has missed some days of school. Plays soccer, and is “OK” with her weight, but is overweight. Admits to trouble sleeping and feeling sluggish. Poor eye contact.
How to ask/respond…
Observe behavior and affect response to questioning about depression and
suicidal thoughts May become belligerent or silly May avoid questions by changing the subject or
not responding
Adapted from pedicases.org
Responses reflect “coping style” Motivational Interviewing techniques may be
useful Be responsive to
maladaptive coping cease discussion if mental status appears too
fragile
Adapted from pedicases.org
HEADSS
Home Education Activities/Exercise Drugs Sex Suicide/Esteem
Difficulty in Identifying Depressed Youth
Bright Futures Developmental Surveillance and School Performance
assess emotional health
What do you do for fun? What are some of the things that worry you? Make you sad?
Make you angry? What do you do about these things? Who do you talk to
about them? Do you often feel sad or alone at a party? Have you ever thought about running away? Leaving
home? Do you know if any of your friends or relatives have tried to
hurt or kill themselves? Do you ever feel really down and depressed? Have you ever thought about hurting yourself or killing
yourself?
Assessment of psychotic features Are they mood congruent? :if hearing voices,
are the things these voices are saying consistent/congruent with a depressed mood (e.g, “you are bad, you should die”), or are they incongruent with depressed mood (e.g., grandiose messages such as, “God has a message for you to share with the human race”)
Adapted from pedicases.org
Need to assess psychotic features
Are they mood congruent? :if hearing voices, are the things these voices are saying consistent/congruent with a depressed mood (e.g, “you are bad, you should die”)
Are they incongruent with depressed mood (e.g., grandiose messages such as, “God has a message for you to share with the human race”)
Neither is good!
Adapted from pedicases.org
Warning Signs
(non specific)
Suicidal talk Preoccupation with death and dying Depression Behavioral changes Giving away possessions Arranging to take care of unfinished business Taking excessive risks Increase drug and/or alcohol use Loss of interest in usual activities
Risk Factors forSuicide in Teenagers
Previous suicidal behavior History of psychiatric disorder or substance abuse Family history of suicide, psychiatric disorder or
substance abuse Parental loss (death or otherwise) History of abuse, violence or neglect Social isolation/alienation Poor communication with parents, decreased
family stability & family violence Stressful life events or loss
Factors that MAY reduce suicide risk
Learned skills & problem-solving Impulse control Conflict resolution Family & community support Access to appropriate mental health care Lack of stigma for treatment Restricted access to lethal methods of suicide Cultural/religious beliefs that discourage suicide
Suicide Risk Assessment
Do you ever have thoughts of hurting yourself in any way? Do you ever think about killing yourself? What do you think about when you think about hurting/killing
yourself? How often do you think about these things? Do you think you might ever do any of these things? Is it possible that you might actually harm yourself or kill yourself? Do you have a plan? When you think about hurting yourself or killing yourself, how do
you imagine you would do it? Do you think you might really do this? Are you able to get the things to enact this plan (e.g., pills, knives,
guns)? What do you think it would be like if you were able to kill yourself? What would it mean to be dead (assess realistic thinking about
death)? Have you ever tried to hurt yourself or kill yourself before? Have you ever known or heard of anyone who killed themselves? How close were you to this person?
Adapted from pediases.org
Referrals Vs. Treatment
Considerations for Treatment Depression or anxiety without suicidal ideation Best to also use CBT
Considerations for Referral Suicidal Ideation Complicated psychosocial situation Multiple Co-morbidities History of Treatment Failures or Unusual responses to
meds
Depression in Adolescents Part II Screening and Assessment
Goals and Objectives
By the end of this learning session, participants will be able to:
To discuss why it is important to diagnose depression in adolescents
To discuss co-morbidities of depression and how they may be related to “risky behavior”
To discuss the differences between dysthymia, major depressive episode, and major depressive disorder
To discuss recommendations for screening tools for depression in children and adolescents
To discuss strategies in interviewing families and patients about depression diagnosis
Key Points
Depression in adolescence is common
“Risky” or “self destructive” behaviors may be self medication or coping for mental health conditions
“Depression” has many forms, and use of DSM-IV diagnostic criteria is important
There are many screening tools for depression…use them as adjunct for face to face conversation
Depression in AdolescentsPart III
Preeti Patel Matkins, MDTeen Health Connection
Levine Children’s HospitalCharlotte, NC
2008
We’ve Moved!
Depression in Adolescents
Part I Overview”Through My Eyes”
Part II Screening and Assessment
Part III Treatment