Recognizing and Managing Depression in Primary CareCharles E. Irwin, Jr., MDDivision of Adolescent MedicineDepartment of PediatricsUniversity of California, San FranciscoFebruary 2014USPSTF RecommendationScreening of adolescents (12-18 yrs) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (CBT or interpersonal) and follow up. March 2009 http:/www.ahrq.gov/clinic/uspstf09/depression/chdeprrs.htm OutlineGeneral OverviewHow to Make the DiagnosisHx takingPhysical examScreening InstrumentsEpidemiologyManagementMajor Depressive DisorderPrimary care clinicians say of the teens they see: - 9-21% have MDDImpact school performanceSubstance use/abuseAssociated with increased risk of suicidal behaviorPossible Symptoms of MDDAppetite disturbanceSleep disturbanceFatigue or loss of energyCardiopulmonary symptomsGI symptomsNeuromuscular symptomsGynecological symptomsDermatological symptomsBehavioral symptomsHistory and Physical ExamPatient historyHEADSSSFamily history (may need to ask parents separately)Complete physical examBMI Neuro examConsider labsHEEADSSSHomeEducation/EmploymentEatingActivitiesDrugsSexSuicide/Safety StrengthsSIGECAPSlooks for criteria for Major Depressive DisorderS - Sleep disturbance: insomnia or hypersomniaI - Interest or pleasure: diminished in almost all activitiesG - Guilt: feelings of excessive worthlessness or guiltE - Energy: fatigue or energy loss nearly every dayC - Concentration: diminished. A - Appetite: weight loss or decreased appetite P - Psychomotor agitation or retardationS - Suicide: recurrent thoughts of death or suicidal ideationScreening InstrumentsPHQ-APatient Health Questionnaire for AdolescentsBDI PCBeck Depression Inventory Primary CareSymptoms and Criteria for a Major Depressive EpisodeDepressed mood or loss of interest or pleasure for a 2-week period (or irritability among children and adolescents), plus:Four or more of the following symptoms in the same 2-week period:Significant weight loss (when not dieting) or weight gain Insomnia or hypersomnia nearly every dayBeing restless or being slow (psychomotor agitation or retardation)Fatigue or loss of energy nearly every dayFeelings of worthlessness or excessive or inappropriate guiltInability to concentrateRecurrent thoughts of death or suicide ideations or plansDSM VSymptoms in Adolescents DSM-IV sx of MDDAs seen in teens Depressed mood most of the dayIrritable or cranky moodLoss of interest in once favorite activitiesLoss of interest in sports, video games, activities with friendsWeight loss/gainSomatic complaints, failure to gain wtInsomnia/hypersomniaExcess late night TV, refusal to wake for schoolPsychomotor agitation/retardationTalk of running away from homeFatigue, loss of energyPersistent boredomDecreased concentration, indecisivePoor school performance, frequent absencesLoss of self esteem, guiltOppositional/negative behaviorDepressive Symptoms in TeensMore sleep and appetite disturbances, delusions, suicidal ideation and attempts, and impairment of functioning than younger children with MDDMore behavioral problems and fewer neurovegetative symptoms than adults with MDD Differential Diagnosis of DepressionAnemiaMononucleosisHypothyroidismHyperthyroidismInflammatory bowel diseaseCollagen vascular diseaseMajor Depression & Co-morbidity76% with major depression also had other diagnoses, two thirds of which preceded the depression diagnosis.Previous diagnoses among the 76% include: Anxiety disorders (40%) Conduct disorders (25%) Addictive disorders (12%)Source: Kessler, 1998Symptoms of Bipolar disorder in Adolescence: Markedly labile moodAgitated behaviorPressured speechRacing thoughtsSleep disturbancesReckless behaviorsIllicit activitiesSpending spreesPsychotic symptoms such as hallucinations, delusions, irrational thoughtsRisk factors for DepressionGenetics20% have + family hx; female genderBiologypuberty, premenstrual, postpartumEnvironmentFamily conflict, substance use at homeNegative life eventsDivorce, loss of parentIndividual factorsPoor self esteem, poor school performanceCo morbiditiesMental healthChronic medical conditionsEpidemiology of DepressionPrevalence of MDD in children ( 13 y.o.) is 2.8%, with 1:1 ratio of girls to boysIn adolescence (13-18 y.o.), prevalence is 5.6%, with a higher prevalence for girls than boys (5.9% vs. 4.6%)Lifetime prevalence among adolescents is 20%.SOURCE?Depression: Broad MeasureSource: Grunbaum et al., 2008; YRBS; Self-reportSadness or Hopelessness which Prevented Usual Activities by Gender and Race/Ethnicity, High School Students, 200734.6 %17.8 %34.5 %24.0 %42.3 %30.4 %35.8 %21.2 %Depression: Broad MeasureSource: Grunbaum et al., 2008; YRBS; Self-reportSadness or Hopelessness which Prevented Usual Activities by Gender and Race/Ethnicity, High School Students, 2011Suicide: Seriously ConsideredGender and Race/Ethnicity, High School Students, 200817.8 %10.2 %18.0 %8.5 %21.1 %10.7 %18.7 %10.3 %Source: Grunbaum et al., 2008; YRBS; Self-reportEpidemiology of DepressionAt any given time, up to one in 13 adolescents have major depression making it more common than asthma Each successive generation since 1940 is at greater risk of developing depression, and is identified at a younger agePrognosis70% of youth with a major depressive episode will have another episode in next 5 yearsYouth with depression have a 4x increased risk of an adult depressive disorder20-40% of children with major depression will develop bipolar disorder eventuallyCan lead to impaired functioning in relationships, school etcPrinciples of TreatmentEnsure safetyDevelop an alliance with the teen and parents Confidentiality?Psycho-educationAddresses signs and symptoms of depressionStresses importance of psychotherapy and psychiatric medicationsAddresses misconceptionsIndications for PCP Care vs. Specialist in Adolescents with DepressionIndications for PCPInitial episode of depressionAbsence of coexisting conditionsAbility to make a no suicide contractIndications for SpecialistChronic, recurrent depressionLack of response to initial treatmentCoexisting substance abuseRecent suicide attempt or current suicidal ideationPsychosisBipolarHigh level of family discordInability of family to monitor patients safety Depression-Treatment OptionsCognitive Behavioral Therapy (CBTInterpersonal therapyPharmacotherapyFirst line therapy, SSRIs Others SNRIs, Buproprion, TCAs, Combinations of the above methods works bestFamily therapyABCs of CBTYou cannot control how you feel, but you can control what you think about, and this can influence how you feelCognitive Behavioral TherapyTreatment targets patients thoughts and behaviors to improve moodEssential elements of CBT include:increasing pleasurable activitiesreducing negative thoughts and improving assertiveness and problem-solving skills to reduce feelings of helplessness.Interpersonal Therapy for DepressionInterpersonal problems may cause or exacerbate depression and that depression, in turn, may exacerbate interpersonal problems.Treatment will target patients interpersonal problems to improve both interpersonal functioning and his/her mood.Pharmacological TreatmentSelective Serotonin Reuptake Inhibitors (SSRIs) are first line for medication for adolescents for depression and anxietyFluoxetine, only drug approved for treatment of MDD among youth.What is a “Black Box Warning?”It is a required statement on the package insert that accompanies every prescription It is the strongest warning from the FDA to prescribers and patients regarding possible adverse effects of a medicationHOWEVER, it is not a contraindication for use of a medicationBlack Box WarningFDA put on all antidepressants in 2004.“.increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) or other psychiatric disorders.” Rx with SSRIs leads to 1-2% absolute increase in risk of suicidalityIf starting an antidepressantConfirm your diagnosisBDI, PHQ-A Start low and advance slowlyFollow up frequently-the black box warning recommends weekly for the first 4 weeks and when a dosage change is made If no improvement after 6 weeks consider changing meds and reconfirm diagnosisIf the patient has a family member who has had a good response to a particular SSRI, that may be helpful in selecting a medication. Talking Points to Patients and Families about SSRIsNeed to supervise medication administration;If your child has threatened or attempted suicide, keep medication in a secure location.Likely duration of medication treatment 6 months to 1 year after symptoms improve and sometimes longerMedication should be stopped gradually under doctors supervision, due to the possibility of withdrawal symptomsSSRIs Side EffectsNauseaLoss of appetiteGI upsetMinimal weight lossHeadacheAgitationAkasthesiaSexual dysfunctionIncreased clotting timeHypomania or maniaSedation or insomniaVivid dreamsQuestions at Follow UpMissed dosesStomachaches/HeadachesRestlessnessUnsettled thoughtsSuicidal thoughtsPositive effectsInitial StrategiesKnow the resources in your communityEducation for patients and familiesNo suicide contractsRemoving firearms, medications, sharp objects from where they are accessible. SummaryMajor burden disabling condition Hx taking/Screening tests are effective in making dx of MDDEffective treatment leads to decrease in symptoms & improved functioningHarm from treatment minimal Centers for Disease Control and Prevention (CDC), Youth Risk Behavioral Surveillance System, U.S. 2007, MMWR, June 6, 2008/ Volume 7/ Number SS-4, http:/www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf , Accessed 05/01/09.Goldenring JM, Rosen DS. Getting into adolescent heads: An essential update. Contemporary Pediatrics 2004;21:64-90Graber JA, Sontag LM. Internalizing Problems during Adolescence. In: Lerner RM, Steinberg L, eds. Handbook of Adolescent Psychology, 3rd edition. Hoboken, NJ: Wiley, 2009Hagan JF, Shaw JS and Duncan PM (eds.). Bright Futures, 3rd Edition. Vol. Hagan JF, Shaw JS, Duncan PM (eds) Bright Futures, 3rd Edition, Elk Grove Village, IL: American Academy of Pediatrics, 2008. Elk Grove Village, IL: American Academy of Pediatrics, 2008Kessler RC, Walters EE. 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