Adolescent Mental Adolescent Mental Health in Primary Care: Health in Primary Care:

DepressionDepression

Karen Soren, M.D.Karen Soren, M.D.Director, Adolescent MedicineAssociate Clinical ProfessorPediatrics & Public HealthColumbia University Medical Center

Why is adolescent depression Why is adolescent depression significant?significant?

Epidemiology:Epidemiology: Point prevalence ranges from 3%-9%.Point prevalence ranges from 3%-9%. By age 18, 20% of teens have had a By age 18, 20% of teens have had a

depressive episode.depressive episode. Incidence increases with age.Incidence increases with age. Mood disorders account for the Mood disorders account for the

majority of adolescent suicides (which majority of adolescent suicides (which is third leading cause of death in is third leading cause of death in adolescents)adolescents)

Depression in adolescents:Depression in adolescents:timing of presentationtiming of presentation

►Depression often first presents during Depression often first presents during adolescenceadolescence Susceptibility of developing brainSusceptibility of developing brain Sleep disturbancesSleep disturbances Hormonal changesHormonal changes Substance abuseSubstance abuse Psychosocial pressuresPsychosocial pressures

Depression in Adolescents:Depression in Adolescents:ConsequencesConsequences

►Subsequent mood episodes, including hypomania/mania (20- 40%)

►School underachievement and failure►Peer and family relationship problems►Suicide attempts, completed suicide,

accidental deaths ► Long-term educational and social difficulties►Substance abuse, antisocial behavior, high-

risk behavior

Importance of Screening for DepressionImportance of Screening for Depression

► The disorder is often unrecognized:The disorder is often unrecognized: stigma stigma parents may not be aware of the disorderparents may not be aware of the disorder signs may be dismissed as “typical teenager” signs may be dismissed as “typical teenager”

behavior behavior children and teens may actively hide the disorderchildren and teens may actively hide the disorder

► Only 25-33% of depressed youths are receiving Only 25-33% of depressed youths are receiving treatment for this disorder (Burns et al 1995, Leaf treatment for this disorder (Burns et al 1995, Leaf et al 1996)et al 1996)

Manifestations of Depression Manifestations of Depression In AdolescentsIn Adolescents

►withdrawal from social activities► irritability► self-criticism► low self-esteem► frequent aches and pains, somatic somatic

symptoms symptoms ► tearfulness and crying

Manifestations of Depression Manifestations of Depression In AdolescentsIn Adolescents

► distinct and enduring mood / distinct and enduring mood / behavioral changebehavioral change

► school problems / underachievement / school problems / underachievement / failurefailure

► family conflictsfamily conflicts► illicit substance use and abuseillicit substance use and abuse► suicidal crisessuicidal crises

Diagnosis of DepressionDiagnosis of Depression

► The formal diagnosis for Major Depressive The formal diagnosis for Major Depressive Disorder was conceptualized for adults.Disorder was conceptualized for adults.

► Depression is defined by the DSM-IV as follows:Depression is defined by the DSM-IV as follows:

Five (or more) Five (or more) of the following symptoms have of the following symptoms have been present during the same 2-week period been present during the same 2-week period and represent a change from previous and represent a change from previous functioning; at least one of the symptoms is functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest either (1) depressed mood or (2) loss of interest or pleasure (see next slide):or pleasure (see next slide):

Diagnosis of Depression: DSM-4Diagnosis of Depression: DSM-4

(1) depressed mood (1) depressed mood Note: In children and adolescents, this can Note: In children and adolescents, this can present as irritable mood.present as irritable mood.

(2) diminished interest or pleasure in all, or almost all, activities (2) diminished interest or pleasure in all, or almost all, activities

(3) appetite and weight changes(3) appetite and weight changes

(4) sleep pattern disruption(4) sleep pattern disruption

(5) psychomotor agitation or retardation(5) psychomotor agitation or retardation

(6) fatigue or loss of energy(6) fatigue or loss of energy

(7) feelings of worthlessness or excessive or inappropriate guilt (7) feelings of worthlessness or excessive or inappropriate guilt

(8) diminished ability to think or concentrate, or indecisiveness(8) diminished ability to think or concentrate, or indecisiveness

(9) recurrent thoughts of death (not just fear of dying), recurrent (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicideor a specific plan for committing suicide

Diagnosis of Depression: DSM-4Diagnosis of Depression: DSM-4

►DSM-IV criteria for depression in children DSM-IV criteria for depression in children and adolescents are essentially similar to and adolescents are essentially similar to adults except:adults except: Irritability can be the primary mood Irritability can be the primary mood

symptom instead of sadness in individuals symptom instead of sadness in individuals under the age of 18.under the age of 18.

Failure to meet normal expected growth Failure to meet normal expected growth milestones can be substituted for the milestones can be substituted for the weight loss criteria.weight loss criteria.

Diagnosis of Depression: DSM-4Diagnosis of Depression: DSM-4Additional CriteriaAdditional Criteria

► Symptoms cause clinically significant Symptoms cause clinically significant distress/ impairment in social, distress/ impairment in social, occupational functioningoccupational functioning

► Symptoms not due to the direct Symptoms not due to the direct physiological effects of a substance (drug physiological effects of a substance (drug of abuse, medication) or general medical of abuse, medication) or general medical condition (ie hypothyroidism)condition (ie hypothyroidism)

► Symptoms not better accounted for by Symptoms not better accounted for by bereavement (if symptoms persist > 2 bereavement (if symptoms persist > 2 mos after loss of a loved one)mos after loss of a loved one)

Spectrum of Depression:Spectrum of Depression:

► Major Depressive Disorder, Single EpisodeMajor Depressive Disorder, Single Episode► Major Depressive Disorder, RecurrentMajor Depressive Disorder, Recurrent► Dysthymic DisorderDysthymic Disorder► Adjustment Disorder with Depressed MoodAdjustment Disorder with Depressed Mood► Adjustment Disorder with Mixed Anxiety and Adjustment Disorder with Mixed Anxiety and

Depressed MoodDepressed Mood► Depressive Disorder Not Otherwise SpecifiedDepressive Disorder Not Otherwise Specified► Bipolar DisorderBipolar Disorder► Substance-Induced Mood DisorderSubstance-Induced Mood Disorder

What Causes Depression in Children and What Causes Depression in Children and Adolescents?Adolescents?

► Biologic correlates: Biologic correlates:

genetics, neuroendocrine, neurotransmitters, genetics, neuroendocrine, neurotransmitters, temperament, sleep abnormalities, brain temperament, sleep abnormalities, brain anatomy/dysfunctionanatomy/dysfunction

► Psychological correlates: Psychological correlates:

dysfunctional attitudes, affect regulation dysfunctional attitudes, affect regulation problems, sexual identity issues, negative life problems, sexual identity issues, negative life events (loss, failure), abuse, co-morbid events (loss, failure), abuse, co-morbid psychiatric disorderspsychiatric disorders

► Social correlatesSocial correlates

Parental depression Parental depression

Primary Care as Primary Care as

Place for IdentificationPlace for Identification ► Extensive literature in adult primary care Extensive literature in adult primary care

about identification and treatmentabout identification and treatment► Integrated models show improved outcomesIntegrated models show improved outcomes► Improved identification without other Improved identification without other

changes have little or no effect on outcomechanges have little or no effect on outcome

Recommendations:Recommendations:

► April 2009: US Preventive Services Task April 2009: US Preventive Services Task Force endorsed depression screening in Force endorsed depression screening in pediatric primary care only for teens ages pediatric primary care only for teens ages 12-18 12-18

►No evidence of utility for screening in No evidence of utility for screening in younger childrenyounger children

► Adult recommendations for screening Adult recommendations for screening already existed as of May 2002 already existed as of May 2002

► Screening only useful if systems in place to Screening only useful if systems in place to ensure accurate diagnosis, therapy and ensure accurate diagnosis, therapy and follow-upfollow-up

Identification of Depression in Pediatrics/ Identification of Depression in Pediatrics/ Adolescent MedicineAdolescent Medicine

How is depression identified in the office How is depression identified in the office setting?setting?

► Patient Interview/ ComplaintsPatient Interview/ Complaints

► Parental Interview/ ComplaintsParental Interview/ Complaints

► Screening ToolsScreening Tools

Patient InterviewPatient Interview

►HEADSS Interview HEADSS Interview includes depression and suicidality questionsincludes depression and suicidality questions

► Issues: Issues: Do physicians have time for full interview?Do physicians have time for full interview? Are they trained to ask these questions in a Are they trained to ask these questions in a

productive way?productive way? Will adolescents be forthcoming?Will adolescents be forthcoming? Should questions be asked only at scheduled Should questions be asked only at scheduled

health maintenance visits, or at all visits?health maintenance visits, or at all visits?

Parental ComplaintsParental Complaints

► Pros:Pros: In children, parental complaints increase the In children, parental complaints increase the

likelihood that pediatricians will identify likelihood that pediatricians will identify psychosocial issues.psychosocial issues.

In adolescents, parental awareness of depression In adolescents, parental awareness of depression in their children will increase access to mental in their children will increase access to mental health services.health services.

► Cons:Cons: Few parents are aware of their adolescent’s Few parents are aware of their adolescent’s

symptoms (Logan and King, 2002)symptoms (Logan and King, 2002) Adolescents may arrive without their parents.Adolescents may arrive without their parents.

Screening InstrumentsScreening Instruments

►Pros:Pros: Increased identification possibleIncreased identification possible Universal screening possible, Universal screening possible,

recommended by some recommended by some Time efficient in waiting roomTime efficient in waiting room May increase adolescent disclosure of May increase adolescent disclosure of

symptomssymptoms

Screening InstrumentsScreening Instruments

►Cons:Cons: Time consuming to screen allTime consuming to screen all Burdon on system Burdon on system Many instruments available – how do Many instruments available – how do

you choose (PHQ-A, Becks)you choose (PHQ-A, Becks) False-positives possibleFalse-positives possible Improved outcomes depend on proper Improved outcomes depend on proper

follow-up of positive screensfollow-up of positive screens

The Diagnostic ProcessThe Diagnostic Process

► Best if collateral information collected Best if collateral information collected (from parent, school, etc)(from parent, school, etc)

► Positive screens/questions should be Positive screens/questions should be followed up:followed up: Suicidality must be addressed Suicidality must be addressed

Safety issues – may need to send to Safety issues – may need to send to Emergency RoomEmergency Room

The Diagnostic ProcessThe Diagnostic Process

►Co-morbidity is the rule, not the Co-morbidity is the rule, not the exceptionexception

Depression frequently co-occurs with Depression frequently co-occurs with anxiety disorders, ADHD, oppositional anxiety disorders, ADHD, oppositional defiant disorder, conduct disorder, defiant disorder, conduct disorder, substance abuse, etc.substance abuse, etc.

►Must rule-out bipolar disorderMust rule-out bipolar disorder

Confidentiality Issues in Depression and Confidentiality Issues in Depression and Suicide ScreeningSuicide Screening

► Legality of breaking confidentiality varies by Legality of breaking confidentiality varies by statestate

►Must break confidentiality when teen is Must break confidentiality when teen is danger to self or others danger to self or others

► Clinician needs to judge when parental Clinician needs to judge when parental involvement is beneficial or harmfulinvolvement is beneficial or harmful

Treatment Issues in Pediatric Treatment Issues in Pediatric And Adolescent DepressionAnd Adolescent Depression

►Who needs treatment? Who needs treatment? Treat persistent depressionTreat persistent depression Treat dysfunction Treat dysfunction Determine if watchful waiting is Determine if watchful waiting is

appropriateappropriate Reassess the patient in 2-4 weeks Reassess the patient in 2-4 weeks

from the initial evaluation to from the initial evaluation to determine persistencedetermine persistence

TADS-Treatment for Adolescents with TADS-Treatment for Adolescents with Depression Study (Depression Study (JAMAJAMA, 2004), 2004)

► 439 patients 12-17 with depression (MDD) at 13 US academic 439 patients 12-17 with depression (MDD) at 13 US academic or community centersor community centers

► RCT of effects of four 12-wk treatments (fluoxetine alone, CBT RCT of effects of four 12-wk treatments (fluoxetine alone, CBT alone, CBT plus fluoxetine, and placebo)alone, CBT plus fluoxetine, and placebo)

► Placebo and fluoxetine administered double-blindedPlacebo and fluoxetine administered double-blinded

► Results: Response to fluoxetine plus CBT (71%) better than Results: Response to fluoxetine plus CBT (71%) better than placebo (35%) or either modality alone (fluoxetine-61% and placebo (35%) or either modality alone (fluoxetine-61% and CBT-43%)CBT-43%)

► Results: Fluoxetine alone better than CBT aloneResults: Fluoxetine alone better than CBT alone

► Results: Clinically significant suicidal thinking (present in 29% Results: Clinically significant suicidal thinking (present in 29% of sample at baseline) improved in all 4 treatment groupsof sample at baseline) improved in all 4 treatment groups

► 1.6% sample attempted suicide (no completed suicides) 1.6% sample attempted suicide (no completed suicides)

TADS – After 36 weeksTADS – After 36 weeks

► Treated placebo group after week 12 but excluded them Treated placebo group after week 12 but excluded them from analysisfrom analysis

► Rates of response: 85%- combination therapy, 69% -Rates of response: 85%- combination therapy, 69% -fluoxetine therapy, and 65% for CBT at week 18 fluoxetine therapy, and 65% for CBT at week 18

► Rates of response: 86% -combination therapy, 81%- Rates of response: 86% -combination therapy, 81%- fluoxetine therapy, and 81% -CBT at week 36fluoxetine therapy, and 81% -CBT at week 36

► Suicidal ideation decreased with treatment, but less so with Suicidal ideation decreased with treatment, but less so with fluoxetine therapy than with combination therapy or CBT. fluoxetine therapy than with combination therapy or CBT.

► Suicidal events -more common in fluoxetine therapy (14.7%) Suicidal events -more common in fluoxetine therapy (14.7%) than combination therapy (8.4%) or CBT (6.3%). than combination therapy (8.4%) or CBT (6.3%).

► CONCLUSIONS: In adolescents with moderate to severe CONCLUSIONS: In adolescents with moderate to severe depression, treatment with fluoxetine alone or in depression, treatment with fluoxetine alone or in combination with CBT accelerates response. Adding CBT to combination with CBT accelerates response. Adding CBT to medication enhances safety of medication. medication enhances safety of medication.

► Taking benefits and harms into account, combined Taking benefits and harms into account, combined treatment appears superior to either monotherapytreatment appears superior to either monotherapy

Cognitive Behavioral TherapyCognitive Behavioral Therapy

Principle of CBT is that thoughts influence Principle of CBT is that thoughts influence behaviors and feelings, and vice versa. behaviors and feelings, and vice versa.

Treatment targets patient’s thoughts and Treatment targets patient’s thoughts and behaviors to improve his/her mood.behaviors to improve his/her mood.

Essential elements of CBT include Essential elements of CBT include increasing pleasurable activities increasing pleasurable activities (behavioral activation), reducing negative (behavioral activation), reducing negative thoughts (cognitive restructuring), and thoughts (cognitive restructuring), and improving assertiveness and problem-improving assertiveness and problem-solving skills to reduce feelings of solving skills to reduce feelings of hopelessness.hopelessness.

Interpersonal Therapy-AdolescentInterpersonal Therapy-Adolescent

Principle of IPT-A is that interpersonal problems Principle of IPT-A is that interpersonal problems may cause or exacerbate depression and that may cause or exacerbate depression and that depression, in turn, may exacerbate depression, in turn, may exacerbate interpersonal problems. Treatment will target interpersonal problems. Treatment will target patient’s interpersonal problems to improve both patient’s interpersonal problems to improve both interpersonal functioning and his/her mood.interpersonal functioning and his/her mood.

Essential elements of interpersonal therapy Essential elements of interpersonal therapy include identifying an interpersonal problem include identifying an interpersonal problem area, improving interpersonal problem-solving area, improving interpersonal problem-solving skills, and modifying communication patterns.skills, and modifying communication patterns.

Medications:Medications:

► AntidepressantsAntidepressants SSRI’s are the current medications of choice for SSRI’s are the current medications of choice for

treatment of depressiontreatment of depression Fluoxetine was the only FDA-approved choice for Fluoxetine was the only FDA-approved choice for

depression in children and adolescentsdepression in children and adolescents Since 2004, the FDA has requested a warning (Black Since 2004, the FDA has requested a warning (Black

Box Warning) on all antidepressants, including Box Warning) on all antidepressants, including tricyclics and SSRI’s, for both young adults and tricyclics and SSRI’s, for both young adults and children, about increased risk of suicidalitychildren, about increased risk of suicidality

More recently, Lexapro (escitalopram) also approved More recently, Lexapro (escitalopram) also approved for youth ages 12-17 for treatment of major for youth ages 12-17 for treatment of major depressiondepression

Fluvoxamine (also an SSRI) approved for treatment Fluvoxamine (also an SSRI) approved for treatment of OCD in children and adultsof OCD in children and adults

Medication InformationMedication Information SSRI’s SSRI’s

Generally safe (must be aware of FDA Generally safe (must be aware of FDA warning)warning)

Common side effects: GI disturbance, Common side effects: GI disturbance, changes in appetite, sleep disturbance, changes in appetite, sleep disturbance, sexual dysfunctionsexual dysfunction

Agitation possible initiallyAgitation possible initially Usual duration of medication treatment - Usual duration of medication treatment -

6 months to 1 year after symptoms 6 months to 1 year after symptoms improveimprove

Medication InformationMedication Information SSRI’s SSRI’s

► Side effects - seriousSide effects - serious serotonin syndrome (fever, nausea, serotonin syndrome (fever, nausea,

confusion, hyperthermia, restlessness, confusion, hyperthermia, restlessness, etc.)etc.)

akathisiaakathisia precipitation of maniaprecipitation of mania anaphylaxisanaphylaxis discontinuation syndrome (dizziness, discontinuation syndrome (dizziness,

drowsiness, nausea, lethargy, headache)drowsiness, nausea, lethargy, headache)

Medication InformationMedication Information SSRI’s SSRI’s

Recent FDA warning regarding suicide and Recent FDA warning regarding suicide and SSRI’s: How can it be understood?SSRI’s: How can it be understood?►Discontinuation issue? (Is it only in patients who Discontinuation issue? (Is it only in patients who

skip doses or stop abruptly?)skip doses or stop abruptly?)►Suicide as an aspect of depression/anxiety? Suicide as an aspect of depression/anxiety?

(Was the difference from the placebo group a (Was the difference from the placebo group a failure of randomization?)failure of randomization?)

►Akathasia left untreated? (Did patients Akathasia left untreated? (Did patients complain?)complain?)

►If true/real, then how about the recent study If true/real, then how about the recent study showing a decrease in suicide rates in areas of showing a decrease in suicide rates in areas of increased SSRI’s prescriptions? increased SSRI’s prescriptions?

Medication InformationMedication Information SSRI’s- First Line SSRI’s- First Line

MedicationMedication Starting Starting DoseDose

IncrementsIncrements Max DailyMax Daily

DoseDoseContra-Contra-

IndicatedIndicated

MedicationsMedications

AvailableAvailable

DosesDoses

FluoxetineFluoxetine

(Prozac)(Prozac)

FDA: FDA: MDD/OCDMDD/OCD

10 mg qd10 mg qd 10-20 mg 10-20 mg per doseper dose

60 mg60 mg MAOIsMAOIs 10,20,40 10,20,40 mgmg

90 mg 90 mg weeklyweekly

(Liquid too)(Liquid too)

EscitalopraEscitalopramm

(Lexapro)(Lexapro)

FDA: MDDFDA: MDD

10 mg qd10 mg qd 10 mg per 10 mg per dosedose

30 mg30 mg MAOIsMAOIs 10 mg10 mg

ParoxetineParoxetine

(Paxil)(Paxil)

FDA safety FDA safety warningwarning

10 mg qd10 mg qd 10 mg per 10 mg per dosedose

60 mg60 mg MAOIsMAOIs 10,20,30,40 10,20,30,40 mg (liquid mg (liquid too)too)

SertralineSertraline

(Zoloft)(Zoloft)

FDA: OCDFDA: OCD

25 mg qd25 mg qd 12.5-25 mg 12.5-25 mg per doseper dose

200 mg200 mg MAOIsMAOIs 25,50,10025,50,100

mg (liquid mg (liquid too) too)

CitalopramCitalopram

(Celexa)(Celexa)10 mg qd10 mg qd 10 mg per 10 mg per

dosedose60 mg60 mg MAOIsMAOIs 10,20,40 10,20,40

mgmg

(Liquid too)(Liquid too)

Medication InformationMedication Information Second Line Antidepressants: Second Line Antidepressants:

(Consult Psychiatrist)(Consult Psychiatrist)MedicationMedication StartingStarting

DoseDoseIncrementIncrementss

Max Daily Max Daily DoseDose

SideSide

EffectsEffectsContra-Contra-

indicatedindicated

MedsMeds

AvailableAvailable

DosesDoses

BupropioBupropionn

((WellbutriWellbutrinn

SR)SR)

No studies No studies showing showing efficacy in efficacy in childrenchildren

100 mg100 mg

QDQD100-150 100-150 mg per mg per dosedose

400 mg400 mg Seizures, Seizures, GI, GI, rashes, rashes, HAs, HAs, sleepsleep

MAOIsMAOIs 100, 100, 150,150,

200 mg200 mg

-this is -this is SRSR

VenlafaxinVenlafaxinee

(Effexor (Effexor XRXR))

Wyeth has Wyeth has warned warned not to use not to use in childrenin children

37.5 37.5 mg QDmg QD

37.5 mg 37.5 mg per doseper dose

300 mg300 mg Increased Increased BP, GI, BP, GI, rashes, rashes, HAs, CV HAs, CV effects effects

MAOIs, MAOIs, pressorpressors (e.g.,s (e.g., stimulants, stimulants, asthma asthma meds)meds)

37.5, 75. 37.5, 75. 150 mg150 mg

Monitoring of children and Monitoring of children and adolescents on SSRIs:adolescents on SSRIs:

► USPSTF recommends judicious monitoring of all USPSTF recommends judicious monitoring of all patients started on antidepressants because of patients started on antidepressants because of the risk of adverse events (primarily suicidality) the risk of adverse events (primarily suicidality)

► AAP encourages use of rating scales for AAP encourages use of rating scales for diagnosis of depression at baseline and during diagnosis of depression at baseline and during treatmenttreatment

► Need to regularly monitor efficacy and adverse Need to regularly monitor efficacy and adverse effects once patient starts medseffects once patient starts meds

► Telephone vs face-to-face monitoring depends Telephone vs face-to-face monitoring depends on patient situationon patient situation

► Particular need to monitor during drug Particular need to monitor during drug initiation, titration and discontinuation periodsinitiation, titration and discontinuation periods

ReferencesReferences► Screening and Treatment for Major Depressive Disorder in Screening and Treatment for Major Depressive Disorder in

Children and Adolescents: US Preventive Services Task Force. Children and Adolescents: US Preventive Services Task Force. Pediatrics Pediatrics 2009; 123: 1223-1228. 2009; 123: 1223-1228.

► Screening for Child and Adolescent Depression in Primary Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the US Care Settings: A Systematic Evidence Review for the US Preventative Task Force. Williams et al. Preventative Task Force. Williams et al. Pediatrics Pediatrics 2009; 123: 2009; 123: 716-735. 716-735.

► Fluoxetine, cognitive-behavioral therapy, and their Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004 Aug 18;292(7):807-20. controlled trial. JAMA. 2004 Aug 18;292(7):807-20.

► The Treatment for Adolescents With Depression Study (TADS): The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. March, Silva et long-term effectiveness and safety outcomes. March, Silva et al.al. Arch Gen Psychiatry. 2007 Oct;64(10):1132-43. Arch Gen Psychiatry. 2007 Oct;64(10):1132-43.