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