Major depressive disorder (MDD) is a debilitating condition that has been increasingly recognized among youth

Prevalence of current or recent depression• 3% among children• 6% among adolescents

As many as 1 in 5 teens have history of depression at some point in adolescence

Adolescent-onset MDD is associated with• ↑ risk of death by suicide• ↑ suicide attempts• ↑ recurrence of major depression by young

adulthood• ↑ risk of substance abuse

MDD also associated with• Early pregnancy• ↓ school performance• Impaired work, social, and family functioning

during young adulthood

Despite significant health burden of MDD, the majority of depressed youth do not receive any type of treatment

Diagnosing depression in children is difficult because of their limited language abilities

Many barriers to adolescents receiving specialty mental health services

Primary care settings have become de facto mental health clinics for adolescents

Primary care clinicians feel inadequately trained, supported, or reimbursed for management of MDD

Insufficient evidence for USPSTF to recommend for or against routine screening of children and adolescents

If patients are to benefit from screening, physicians should have systems in place to assure accurate follow-up

According to the USPSTF, an affirmative response to 2 questions

• May be as effective as using longer screening measures or

• May indicate the need for use of more in-depth diagnostic tools

1) “Over the past 2 weeks have you ever felt down, depressed, or hopeless?”

2) “Have you felt little interest or pleasure in doing things?”

Depression screening measures do not diagnose depression, but provide• An indication of severity of symptoms• Assess the severity within a given period of

time Depression screening measures for

children and adolescents are generally appropriate for children who are• > 7 years old• At > 6th grade reading level

Measure

Age appropri-ateness

Reading level

Spanish version

# of items

Time to complete (min)

Children’s Depression Inventory (CDI) 7 – 17 1st Y 27 10 – 15

Center for Epidemiological Studies-Depression Scale for Children (CES-DC)

12 – 18 6th Y 20 5 – 10

Center for Epidemiological Studies-Depression Scale (CES-D) 14+ 6th N 5 – 10

Reynolds Child Depression Scale 8 – 12 2nd Y 30 10 – 15

Reynolds Adolescent Depression Scale 13 – 18 3rd N 30 10 – 15

Beck Depression Inventory (BDI)14+ 6th Y 21 5 – 10

Pediatric Symptom Checklist is an alternative tool for screening children for psychosocial problems• Not specific for depression• 35-item checklist• Parents complete

Persons scoring above established cutoff level should be interviewed for depressive disorders in DSM-IV-TR• Major depressive disorder• Subclinical or minor depression• Dysthymia

Interviews are necessary because screening does not address:• Conditions with symptoms common to

depression• Duration of symptoms• Degree of impairment• Co-morbid psychiatric disorders

In cases of mild depression, consider a period of active support and monitoring before starting other evidence-based treatment• Weekly / bi-weekly visits x 6-8 weeks• A sizable # respond to nondirective therapy

and regular symptom monitoring• Essential when family/patient refuse treatment

The GLAD-PC toolkit provides additional guidance on providing active support

For moderate to severe cases, clinician should recommend:• Treatment• Crisis intervention (as indicated)• Mental health consultation immediately• No period of active monitoring

Start active support and treatment when there is a lengthy wait list for mental health service

Once referral is made, primary care doctor should remain involved in the follow-up

Appropriate roles and responsibilities for ongoing management by primary care and mental health clinician should be:• Communicated• Agreed upon

Help patient and family arrive at treatment plan that is acceptable and implementable

Recommend scientifically tested and proven treatments whenever possible and appropriate to achieve treatment plan goals• Psychotherapies (CBT, IPT) and/or• Antidepressants (SSRIs)

Use common-sense approaches also• Physical exercise• Adequate nutrition

Research evidence supports use of antidepressants in adolescents with MDD• 6x more teens would benefit than would be

harmed• Significant difference between those on

medication vs on placebo• Fluoxetine has largest # of studies with

positive results• Paroxetine has largest # of studies with

negative results

When indicated by clinical presentation (clear dx of MDD w/o comorbid conditions) and patient/family preference, an SSRI should be used• Inform about adverse effects• Know potential drug interactions• Generally, effective dosages in adolescents are

lower than would be found in adult guidelines• Contact pt/family after treatment initiation to

review understanding and adherence

Patients on antidepressants will likely experience adverse effects • Routine monitoring for this is critical

Telephone vs face-to-face• Include:

Nausea Headache Possible switch to mania Behavioral activation / suicidal behavior

FDA recommendations:• “All pediatric patients should be observed

closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases

• Ideally observation face-to-face: Weekly x first 4 weeks, then Bi-weekly x 4 weeks, then At 12 weeks, then As clinically appropriate

Cognitive behavioral therapy (CBT) conducted by trained therapists for mild-to-moderate depression is effective

Few studies have been conducted on depressed adolescents undergoing interpersonal therapy (IPT)

Systematic and regular tracking of goals and outcomes of treatment should be done• Assess depressive symptoms and functioning in

Home School Peer settings

• Depressive symptoms and functional impairment may not improve at same rate

• See patient within 1 week of treatment initiation

At every visit, inquire about:• Ongoing depressive symptoms• Risk of suicide• Possible adverse effects from treatment• Adherence to treatment• New or ongoing environmental stressors

Consult mental health if teen develops psychosis, suicidal or homicidal ideation, or new/worsening comorbid conditions

Antidepressant medication should be continued for 1 year• GLAD-PC and AACAP experts conclude

medication should be maintained for 6-12 months after full resolution of depressive sx

Monitor patients monthly x 6-12 months after full resolution of symptoms• If depressive episode is a recurrence, monitor

for up to 2 years given high recurrence rate

If no improvement in 6-8 weeks, reassess:• Initial diagnosis• Choice and adequacy of initial treatment• Adherence to treatment plan• Presence of co-morbid conditions (ex:

substance abuse) or bipolar symptoms that may influence treatment effectiveness

• New external stressors

If no response to maximum therapeutic dose of antidepressant consider changing med• All SSRIs (except fluoxetine) should be slowly

tapered when discontinued (withdrawal effects) If no improvement on medication or therapy

alone add or switch to other modality After exhausting all approaches and

achieving only partial improvement consider mental health consultation

Brent DA. Antidepressants and pediatric depression--the risk of doing nothing. N Engl J Med. 2004 Oct 14;351(16):1598-601

Brent DA, Birmaher B. Clinical practice. Adolescent depression. N Engl J Med. 2002 Aug 29;347(9):667-71.

Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque D, Stein RE; GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007 Nov;120(5):e1313-26. Review. Erratum in: Pediatrics. 2008 Jan;121(1):227.

Sharp LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use in primary care settings. Am Fam Physician. 2002 Sep 15;66(6):1001-8.