managing adolescent depression in primary care. copyright © the reach institute. all rights...

Managing Adolescent Depression in Primary Care

http://www.thereachinstitute.org/

Copyright © The REACH Institute. All rights reserved.

Learning Objectives

• Identify treatment components of the AAP-approved Guidelines for Adolescent Depression – Primary Care (GLAD-PC)

• Select treatment plans that match MDD severity

• Summarize evidence-based treatments for adolescent MDD

• Describe clinical recommendations when selecting and using SSRI’s with adolescents

• Review safety planning, assessing suicide risk, and discussing the FDA boxed warning


Agenda

• Review treatment of adolescent depression in PCP settings using the GLAD-PC treatment recommendations

• Review and apply GLAD-PC flow chart for adolescent MDD treatment to Jennifer and David

• Peer practice: 1. Safety planning 2. Suicide risk assessment 3. Discussing Boxed Warning with parents

• Expert panel discussion on treating pediatric depression


GLAD-PC Guidelines: Initial Management

• Educate and counsel families and patients about depression and treatment options (Pages 102-110).

• Develop a treatment plan with patients and families with specific goals in key areas of functioning including home, peer, and school.

• Establish collaboration with mental health resources in the community and with other patients and families.

See www.glad-pc.org for entire GLAD-PC toolkit


GLAD-PC Guidelines: Treatment

• Categorize current depressive episodes into one of three levels based on assessment tools and your clinical judgment (See p. 53 for definition and 57-64 for tools)

–Mild depression

–Moderate depression

–Severe depression

See www.glad-pc.org for entire GLAD-PC toolkit


GLAD-PC Guidelines (See next slide in Participant Book)

• Mild (Specific info: patient education / referral / follow-up)– Consider a period of active support and monitoring before

starting other evidence-based treatment. • Moderate

– Consider starting an SSRI or an Evidence Based Psychotherapy (EBP)

• Severe – SSRI’s and EBP are optimal treatment

• Complicating factors/conditions (e.g. co-existing substance use/abuse, self-injury, suicidal ideation (SI))– Consider MH referral or hospitalization


GLAD-PC(Guidelines for Adolescent Depression – Primary Care), p. 16

See www.GLADPC.org for complete toolkit, 1-151 pgs

See WkBk H 1.0

http://www.GLADPC.org/


GLAD-PC(Guidelines for Adolescent Depression – Primary Care), p. 17

See www.GLADPC.org for complete toolkit, 1-151 pgs

a Psychoeducation, supportive counseling, facilitate parental & patient self-management, refer for peer support and regular monitoring of depressive symptoms and suicidality. b Negotiate roles/ responsibilities between primary care and mental health, and designate case co-ordination responsibilities. Continue to monitor in primary care after referral. Maintain contact with MHc Professionals should monitor for changes in symptoms and emergence of adverse events such as increased suicidal ideation, agitation or induction of mania. For monitoring guidelines please refer to guidelines/toolkit.

See WkBk H 1.1

http://www.GLADPC.org/


Evidence Based Psychotherapies for Depression

• Cognitive Behavioral Therapy (CBT)

• Interpersonal psychotherapy- some evidence supporting role in pediatric depression


What about theantidepressant medications?


Treatments for Depression• Pharmacotherapy

• Fluoxetine (Prozac)--FDA approved for pediatric patients 8-18 years of age

• Escitalopram (Lexapro)--FDA approved for adolescents 12-17 years of age

• Psychotherapy: Cognitive Behavioral Therapy (CBT)• Interpersonal psychotherapy- Some evidence

supporting role in pediatric depression• ECT• Light Therapy• TMS (transcranial magnetic stimulation) – Preliminary

study


Antidepressants—Mechanism

• SSRIs selectively block the reuptake of 5-HT (first-line pharmacotherapy)

• TCAs block the reuptake of 5-HT and/or norepinephrine

• MAOIs block monoamine oxidase (MAO), thereby blocking metabolism and increasing neurotransmitter availability in the synapse


MEDICATION Drug Placebo P value

Fluoxetine (Prozac) (March ’04)* 56% 33% 0.02

Fluoxetine (Prozac) (Emslie ’97) 52% 37% 0.03

Fluoxetine (Prozac) (Emslie ’02) 61% 35% 0.001

Paroxetine (Paxil) (Keller ’01)** 66% 48% 0.02

Paroxetine (Paxil) (Unpublished) 69% 57% NS

Paroxetine (Paxil) (Unpublished) 65% 46% 0.005

Citalopram (Celexa) (Wagner ’04) 47% 45% NS

Sertraline (Zoloft) (Wagner ’03) 63% 53% 0.05

Escitalopram (Cipralex) (Emslie ’09) 64% 53% 0.03

*Fluoxetine alone compared to placebo**Paroxetine compared to placebo

Response Rates in RCT’s of Antidepressants (for depression) based on CGI (Clinical Global Impression)


Treatment Tactics—Depression• Initiation

– Minimal or no response: total trial should not exceed 4-8 weeks

– Partial response: trial up to 12 weeks– Monitoring: q1-2 weeks initially

– Initiate 2nd SSRI for non-response to first agent (x-taper)

• Continuation Phase– Continue medications 6-9 months after symptom

remission– When discontinuing, taper no more than 25% per week– Monitor q 2-4 months as relapse most likely in first 8

months

• 60-70% recurrence of MDD in adulthood• Maintenance: 3 years – lifetime (no data)


Nuts and Bolts of SSRIs for Depression

• How to choose an SSRI– Evidence– Drug-drug interactions– Side effect profile– Patient preference – Previous good result with family member

• Starting and titrating– Start low, go slow (refer to SSRI table for starting dose)– Increase to target dose* in 1-4 weeks

• Write prescription that makes increase to target dose• See patient back after 1-4 weeks and increase dose

– Allow for trial of 6-8 weeks

• Discontinuation• Cross taper *probable, effective dose


Adverse events inSSRIs and Non-SSRIs

• Common

• Nausea

• Diarrhea

• Headache

• Feeling tired

• Nervousness

• Agitation

• Sleep difficulties

• Dry mouth

• Sweating

• Tremors

• Feeling dizzy

• Appetite changes

• Rare

• Increased bleeding

• Increased bruising

• Sexual side effects

• Vivid or strange dreams

• Bruxism

• Increased risk of sunburn

• Hair loss

• Difficulty breathing

• Serotonin syndrome

• New onset suicidal ideation?

• Less Common

• Rashes

• Itchiness

• Swelling

• Sexual disturbance

• Problems concentrating

• Blurry vision

• Increased yawning

• Constipation

• Changes in patterns of passing urine

• Akathisia


The FDA Boxed Warning“the Black Box”

• Applies to all medications with FDA indication for depression - Antidepressants (SSRIs & non-SSRI’s)

• Suicidality– Increased risk of suicidality in children, adolescents and

young adults w/ major depressive or other psychiatric disorders especially during the first months of treatment with antidepressants vs. placebo.

– Weigh risk vs. benefit: In short-term studies of antidepressants vs. placebo, suicidality risk was not increased in patients >24 y/o, and risk decreased in patients >65 y/o.

– Observe all pts for clinical worsening, suicidality, or unusual behavior changes


Residual Symptoms & Relapse

• Patients with residual symptoms have an increased risk of relapse

• Partial remission is related to poor outcome in both medication and CBT trials

• Increased risk for relapse (77% vs. 48%) by 36 months if SSRI is discontinued – Emslie et al., 2008


SSRIs for Depression in AdolescentsTRADE NAME GENERIC NAME

AVAILABLE FORMS

DOSINGTARGET DOSE (ADOLESCENT)

FDA INDICATION

COMMENTS

CELEXA citalopramTablets: 10, 20, 40 mgSolution: 10 mg/5ml

Start with 10 mg in am or pmDose range: 10-40 mg daily

20

Adults: MDD

Good side effect profile. Does not usually cause insomnia

LEXAPRO escitalopramTablets: 5, 10, 20 mgSolution: 5 mg/5ml

Start with 5 mg in am or pmPDR: Initial 10 mg qd, in am or pm. Titrate: May increase to 20 mg after 3 weeks.Dose range 5-20 mg

10Adults: MDD & GAD (A)MDD (12-17)

S-isomer of citalopram

PROZAC fluoxetine Tablets: 10, 20, 40 mgSolution: 20 mg/5ml

Start with 10 mg/day. After 1 week at 10 mg/day may increase to 20 mg/dayDose range: 10-60 (doses above 20 often used for OCD)

20

Adults: MDD, OCD, Bulimia Nervosa, Panic, PMDD (A) MDD (8-17 y/o), OCD (7-17 y/o)

Weekly form available. Long half life prevents withdrawal symptoms If dose is missed

ZOLOFT sertraline Tablets: 25, 50, 100 mg Solution: 20 mg/ml

Start with 25 mg per dayDose range: 50-200 mg daily

50-100

Adults: MDD, OCD, Panic, PTSD, PMDD, SAD (A)OCD (6-17 y/o)

Copyright ©2014 The REACH Institute. All rights reserved.


GLAD-PC Guidelines: Ongoing Management

• Perform systematic and regular tracking of goals and outcomes from treatment, including assessment of depressive symptoms and functioning in several key domains: home, school, and peer settings.

• Reassess diagnosis and initial treatment if no improvement is noted after 6-8 weeks of treatment. Mental health consultation should be considered.

• Ask suicidality questions and monitor warning signs.


Peer Practice: Suicide Risk and Safety Planning

• Task One: Read the Unit F workbook pages on suicide risk assessment and preventing suicide(F 1.1 –1.4).

• Task Two: Discuss the boxed warning and safety planning with parent (F1.1-1.3).

– In pairs and using the Boxed Warning and Ways to Prevent Suicide handouts, discuss with the parent how to safety-proof the home and monitor suicide risk.

• Task Three: Volunteer to role play Task 2 with a parent in front of the entire group


Treatment Summary• Involve and educate parents & youth about MDD.

See www.parentsmedguide.org for parent handouts

• Mild depression needs “active monitoring” & support

• Moderate to severe depression may need combined treatment (SSRI plus EBP)

• Any child on medication needs to be monitored closely.

• Medication can be an important component of treatment, but medication alone is rarely the answer. Your active support & monitoring, +/- an EBP (CBT or IPT) always essential.


Ask the Experts:

Treatment of Child and Adolescent Depression


REMINDER: Please fill out Unit H

evaluation


-0.2

0

0.2

0.4

0.6

0.8

1

1.2

1.4Effect SizeHighModerateModest

Trial, Year

Eff

ect

Siz

eRESOURCE SLIDE

Why CBT? Acute CBT Trials in Youth w/MDD

Effect size: .34; Weisz et al., 2006


RESOURCE SLIDEMeta-Analysis of SSRI RCTs

• 27 major depressive disorder (MDD) trials• Pooled risk differences (benefit vs. risk) favored

antidepressants vs. PBO for MDD– Effect size=0.25

• Efficacy moderated by: Age, Duration of MDD, and # of sites in the RCT

• Children < 12 y.o.: only fluoxetine showed benefit over PBO

Bridge JA , et al. JAMA 2007;297:1683-1696


RESOURCE SLIDETADS CDRS Findings:

(Children’s Depression Rating Scale)

30

40

50

60

Baseline Week 6 Week 12

Stage I Assessments

Mean

CD

RS

Sco

re -

Ad

juste

d

COMB

FLX

CBT

PBO

T A D S


RESOURCE SLIDEDiscontinuation symptoms

• Flulike symptoms (e.g., headache, diarrhea, nausea, vomiting, chills, dizziness, fatigue) may occur when suddenly stopping SSRI medications, and this is more common in agents with short half-lives.

• SSRIs also have a higher margin of safety in overdoses compared to TCAs and MAOIs.

• Deaths have been reported with large ingestions of SSRIs (either alone or in combination with other medications).


Emslie Fluox• Emslie et al. Am J

Psychiatry Feb 2008• 102 Adolescents

– Mean age 11.8+2.8 yr.– MDD Responders

• Fluoxetine X 12 Weeks• CGI-S of 1 or 2 & CDRS-R <

28

– Randomized• Fluoxetine• Placebo

– Relapse• Score > 40 CDRS X 2 Weeks

Survival Curve Time to Relapse

RESOURCE SLIDE


RESOURCE SLIDEContinuation Treatment


Resource Slide: GLAD-PC ToolkitResource Slide: GLAD-PC Toolkit• Psychoeducation Materials/Provider

– What to tell parents about depression?

• Psychoeducation Materials for Children/Adolescents– Self-Care Success

• Psychoeducation Materials for Parents– Depression Fact Sheet– FAQs about Antidepressants– Family Support Action Plan (NAMI, DBSA) (long version)

• Other Patient and Family Handouts– Facts on Psychological Counseling– Communication Tools Between Providers

• Suicide– Suicide & SSRIs– Suicide prevention tips

www.glad-pc.orgCopyright ©2014 The REACH Institute. All rights reserved.

managing adolescent depression in primary care. copyright © the reach institute. all rights...

Documents

pediatric depression

reach institute

hospitalization slide

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gladpc guidelines

entire gladpc toolkit

primary care slide

adolescent mdd treatment