paulette pitt, phd kelly a. curran, md, ma · premenstrual dysphoric disorder (pmdd)...

Paulette Pitt, PhD

Kelly A. Curran, MD, MA

Recognize common presenting signs and diagnostic criteria of depression and anxiety in children and adolescents

Identify screening tools for anxiety and depression for use in clinical practice

Conduct suicide screening and recognize a mental health emergency in a pediatric patient

Epidemiology

Diagnostic Criteria

Clinical Presentation

Screening Tools

Self-injury

Suicide Assessment

Epidemiology

Question (in the 12 months before the

study)

United States Oklahoma

Felt sad or hopeless(almost every day for 2 weeks or more in a row so that they stopped doing some usual activities)

31.5% (CI 29.6–33.4%) 31.8% (CI 28.0–35.8%)

Seriously consideredattempting suicide

17.2% (CI 16.2–18.3%) 19.1% (CI 15.8–22.8%)

Made a plan about how they would attempt suicide

13.6% (CI 12.4–14.8%) 13.4% (CI 11.1–16.2%)

Attempted suicide 7.4% (CI 6.5–8.4%) 11.2% (CI 8.9–13.9%)

Suicide attempt resulted in an injury, poisoning or overdose that had to be treated by a doctor or nurse

2.4% (CI 2.1–2.9%) 3.7% (CI 2.5–5.5%)

Adapted from ”Youth Online High School Results” from the CDC, accessed at nccd.cdc.gov

Depression is increasing in the United States◦ Across all populations, even when controlling for demographics

◦ Increasing faster in adolescents

Anxiety disorders are increasing

Suicide on the rise◦ ~45,000 US citizens per year (age 10 and older)

◦ 10th leading cause of all deaths in US

◦ About ½ of suicide deaths had no prior diagnosis of mental illness

◦ 2nd leading cause of death in older teens (age 15-19)

3rd in young teens (age 10-14)

Weinberger AH, Gbedemah M, Martinez AM, et al. Trends in depression prevalence in the USA from 2005 to 2015: widening disparities in vulnerable groups. Psycho Med. Jun; 48(8): 1303-1315.Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance — United States, 2017. MMWR Surveill Summ 2018;67(No. SS-8):1–114. DOI: http://dx.doi.org/10.15585/mmwr.ss6708a1Bitsko RH, Holbrook JR, Reem M, et al. Epidemiology and Impact of Health Care Provider–Diagnosed Anxiety and Depression Among US Children. Journal of Developmental & Behavioral Pediatrics, 2018; 1 DOI: 10.1097/DBP.0000000000000571

http://dx.doi.org/10.15585/mmwr.ss6708a1

http://dx.doi.org/10.1097/DBP.0000000000000571

Hard to estimate true prevalence (disease vs. diagnosis)

Anxiety ~31.9% lifetime prevalence for teens

Depression affects an estimated 13% annually

Mojtabai R, Olfson M, Han B. National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics 2018; e20161878. DOI: 10.1542/peds.2016-1878NIHM. ”Statistics: Major Depression.” Accessed at https://www.nimh.nih.gov/health/statistics/major-depression.shtmlNIMH. “Statistics: Any Anxiety Disorder.” Accessed at https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml

Lots of speculation…◦ Increasing economic factors?

◦ Increasing isolation?

◦ Rise of technology?

◦ Increasing stress/pressures?

◦ Diagnosis bias?

No answers

DSM 5 Diagnoses

Disruptive Mood Dysregulation Disorder

Major Depressive Disorder (MDD)

Persistent Depressive Disorder (Dysthymia)

Premenstrual Dysphoric Disorder (PMDD)

Substance/medication-Induced Depressive Disorder

Depressive Disorder Due to Another Medical Condition

Other Specified Depressive Disorder

Unspecified Depressive Disorder

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

Depressed mood Diminished interests Weight loss or gain Sleep dysregulation Psychomotor interference Fatigue Negative feelings Cognitive interference Suicidal ideation/attempt


Severe recurrent temper outbursts

Outbursts inconsistent with developmental level

Three or more times per week

Mood between outbursts irritable/angry

Present for 12 or more months

Present in two of three settings – severe in at least one setting

Do not diagnose before age 6 years or after age 18 years

CANNOT coexist with ODD, IED, or bipolar disorder


Depressed mood most of day for at least 1 year (children/adolescents)

Two or more◦ Appetite disturbance

◦ Sleep disturbance

◦ Fatigue/low energy

◦ Low self-esteem

◦ Problems concentrating or making decisions

◦ Hopelessness


Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder Panic Disorder Generalized Anxiety Disorder Agoraphobia Anxiety Disorder Due to Another Medical Condition Other Specified Anxiety Disorder Unspecified Anxiety Disorder


Fears social situations in which may be scrutinized

Fears negative evaluation

Social situations provoke fear◦ Crying◦ Tantrums◦ Freezing◦ Clinching◦ Shrinking◦ Failing to speak

Socialization avoided to avoid fear

Out of proportion to actual threat

Lasting at least 6 months


Excessive anxiety/worry◦ More days than not

◦ 6 months

◦ Number of activities/events

Difficult to control worry

Three or more of following:◦ On edge/restless

◦ Fatigued

◦ Problems concentrating/going blank

◦ Irritability

◦ Muscle tension

◦ Sleep disturbance


Recurrent panic attacks◦ Following symptoms:

Palpitations, pounding heart, accelerated heart rate

Sweating

Trembling/shaking

Shortness of breath

Chest pain/discomfort

Feelings of choking

Nausea/abdominal distress

Feeling dizzy/unsteady

Chills/heat sensation

Paresthesias

Derealization

Fear of losing control

Fear of dying


Persistent concern about having additional

Significant maladaptive change in behavior related to attacks


Why Care?

Kids and teens often have different presentations than adults

Few will present to care reporting depression or anxiety◦ Developmentally may not have the language to describe emotions

◦ Families may focus on “outcome” (e.g. bad grades) instead

Clinicians may have to “dig” in the history for clues

Essential to get history separately from the family◦ HEADSS screening in adolescents

Low energy

Excessive worry

Excessive guilt

Anhedonia

Social withdrawal

Behavior problems

Sadness

Irritability

Poor concentration

Anger

Poor school performance

Somatic symptoms

Gudmundsen GR, Rhew IC, McCauley E, et al. J Clin Child Adolesc Psychol 2018;7:1-15. doi: 10.1080/15374416.2017.1410823

Boys more likely to exhibit sad mood, fatigue, and trouble concentrating

Often teens with MDD had symptoms of anxiety and depression present in elementary school

Gudmundsen GR, Rhew IC, McCauley E, et al. J Clin Child Adolesc Psychol 2018;7:1-15. doi: 10.1080/15374416.2017.1410823

Flat, depressed or anxious affect

Psychomotor slowing

Weight changes

Self injury marks (e.g. cutting)

Depression◦ USPSTF: Screen MDD in ages

12-18 (if adequate resources for follow up), grade B Category I for children age 11 and

younger

◦ AAP: Screen MDD annually age 12 and older, grade II At risk patients should be

monitored over time, grade II

Anxiety◦ No USPSTF or AAP

recommendation for anxiety screening

USPSTF. Depression in Children and Adolescents: Screening. Accessed at https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-children-and-adolescents-screening1Zuckerbrot RA, Cheung A, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics 2018; 141(3) e2017408. DOI: 10.1542/peds.2017-4081

https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-children-and-adolescents-screening1

PHQ 9: Modified for Teens◦ Adolescent diagnostic criteria

◦ Language specific to adolescents

◦ Severity indicator

◦ Addresses dysthymia

◦ Suicidality

SCARED◦ Parent

◦ Child

Spence Children’s Anxiety Scale◦ Parent

◦ Child

Beck Youth Inventory, Second Edition

Incredibly common!◦ 15 % of teens

◦ 17 % - 35 % of college students

Onset age 14 – 24

Bimodal peak ages 12- 14 and ages 18 - 19

Kerr PL, Muchlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med 2010; 23(2): 240-59.

Cutting*

Skin carving

Burning*#

Abrading/scratching

Punching/hitting#

Biting

Inserting sharp objects under skin

Bone breaking

Auto amputation

Ocular enucleation

# Most common SI in men* Most common SI in women


Borderline Personality Disorder: 70 – 75 % have SI

Dissociation and Dissociative Disorders: 69 % have SI

~42% of those with SI meet criteria for MDD


Disclosure Provide understanding of behavior Validating Motivational interviewing◦ Understand function of behavior◦ Risk assessment◦ Motivate treatment receptivity

Assessment◦ Severity of SI (frequency, number of methods)◦ Risk of suicide attempt◦ Regular assessment of high risk patients


STOPS FIRE ◦ Suicidal ideation during or before SI

◦ Types of SI

◦ Onset of SI

◦ Place (location) on body

◦ Severity/extent of damage

◦ Functions of SI

◦ Intensity of SI

◦ Repetition of SI

◦ Episodic frequency of SI


Family history of suicide attempts

Exposure to violence

Impulsivity

Aggressive behavior

Access to firearms

Bullying

Helplessness

Hopelessness

Loss

Rejection

American Academy of Child and Adolescent Psychiatry. Facts for Families: Teen Suicide. Accessed at www.aacap.org/AACAP/Families_and_youth/Facts_for_families/FFF-Guide/Teen-Suicide-010.aspx

Making statements

Change in eating habits

Change in sleep patterns

Withdrawal

Complaints about physical symptoms

Decline in grades

Preoccupation with death/dying

Failure to plan for future

Giving away possessions

American Academy of Child and Adolescent Psychiatry. Facts for Families: Teen Suicide. Accessed at www.aacap.org/AACAP/Families_and_youth/Facts_for_families/FFF-Guide/Teen-Suicide-010.aspx

Psychiatric diagnoses Thoughts of death Suicidal ideation Plan for suicide Means available Intent Impulse control Protective factors Family history of suicide Previous attempts

McDowell AK, Lineberry TW, Bostwick JM. Practical Suicide Risk Management for the Busy Primary Care Physician. Mayo Clin Proc. 2011; 86(8): 792 -

800. doi: 10.4065.mcp.2011.0076

Medication initiation

Individual and group psychotherapy

Rest

Social services intervention

Identification of supports

Educating family on removing harmful items

Provide crisis line numbers

McDowell AK, Lineberry TW, Bostwick JM. Practical Suicide Risk Management for the Busy Primary Care Physician. Mayo Clin Proc. 2011; 86(8): 792 -

800. doi: 10.4065.mcp.2011.0076

40% of SI have suicidal thoughts while engaged in SI

50 – 85% have attempted suicide

Those who attempt have longer histories of SI and varied methods of SI

As severity of SI increases, suicidality increases

Kerr PL, Muchlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med. 2010; 23(2):240-59.

Differentiation of SI and suicidality◦ Intent – SI reducing emotional distress/increase positive affect, not

death; 1.4 – 2 % deaths (cutting)

◦ Method – lethal vs. nonlethal behaviors

◦ Psychological impact

Repeated/chronic behavior

¼ of SI engage in 11 – 50 episodes of SI

9.9 % = >50 episodes


SI likely to convert if repulsed by life

Attracted to death

Unafraid of suicide/death

Chronically self-critical

Apathetic

Tenuous family connections (parental criticism)


paulette pitt, phd kelly a. curran, md, ma · premenstrual dysphoric disorder (pmdd)...

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