Management of Adolescent Depression

1. Management of Adolescent Depression Amy Cheung, MDYouth DivisionDepartment of PsychiatrySunnybrook Health Sciences Centre

2. Outline • Background • Guidelines for Adolescent Depression in Primary Care (GLAD PC) • Development Process • Recommendations • Implementation plans

3. Major Depressive Disorder in Adolescents • Common in adolescence – 8% lifetime prevalence • Significant burden of illness on patients and families • High rates of MDD in primary care settings - up to 28% • 50% of youth with MDD missed in primary care settings • Most clinicians think it is their responsibility to identify depression Cheung et al., 2006;Bartlett et a., 1991;Chang et al., 1988; Kramer & Garralda, 1998;Olson et al., 2001;Jensen, 2002

4. Major Depressive Disorder in Adolescents • Most clinicians “intend” to screen for depression and suicide, but do it less often than other areas (sexual activity/birth control), only 15% and 17% do it always • Shortage of mental health professionals in both US and Canada • Barriers to accessing services – only 50% utilize services • Critical to improve collaborative care in Canada Halpern-Felsher et al, 2000; Middleman et al., 1995; Kates et al., 1996;Cheung et al., 2007

5. GLAD-PC Steering Committee& Liaisons Steering CommitteeOrganizational Liaisons Boris Birmaher, MD John Campo, MD Darcy Gruttadaro (NAMI) Greg Clarke, PhD Dave Davis, MD Sue Bergeson (DBSA) Allen Dietrich, MD Graham Emslie, MD Mike Faenza (NMHA) Bernard Ewigman, MD Eric Fombonne, MD Eric Fombonne (CPA, CACAP) Sherry Glied, PhD, Kimberly Hoagwood, PhD Ben Vitiello (NIMH) Charles Homer, MD Danielle Laraque, MD James MacIntyre (AACAP) Miriam Kaufman, MD Kelly J. Kelleher, MD Bruce Waslick (AMA) Stanley Kutcher, MD Michael Malus, MD Deborah Ebner (SAM) James Perrin, MD Harold Pincus, MD Diane Sacks (CPS, AAP) Brenda Reiss-Brennan, RN Diane Sacks, MD Michael Malus (CCFP) Ruth E. K. Stein, MD Bruce Waslick, MD Angela Diaz (AAP) Angela Diaz, MD Judy Garber (APA) Jim Perrin (AAP) Kelly Kelleher (AAP) David Fassler (APA) Bernard Ewigman (AAFP) Stanford Friedman (SDBP) Sandra Spencer (FFCMH) Vicky Wolfe (CPA)

6. GLAD-PC Support Project Team Peter S. Jensen, MD Amy Cheung, MD, Rachel Zuckerbrot, MD Kareem Ghalib, MD Anthony Levitt, MD Funders CSAT, SAMHSA Josiah Macy, Jr. Foundation NY Office of Mental Health Lowenstein Foundation University of Toronto AAP NY Chapters 1,2&3, District II NY Council C&A Psychiatry NY Academy of Medicine Kellogg Foundation Civic Research Institute, Inc.

7. GLAD-PC Development Process • Initial partnership between the Center for the Advancement of Children’s Mental Health, Columbia University and University of Toronto • 16 focus groups: primary care providers, adolescents, parents (n>100) • Systematic Evidence-Based Literature Reviews • Consensus Survey and Conference

8. GLAD PC • Surveillance and Identification • Assessment and Diagnosis • Initial Management • Treatment • Ongoing Management

9. GLAD-PC Guidelines: Identification/Surveillance Recommendation I: Patients with depression risk factors (such as history of previous episodes, family history, other psychiatric disorders, substance abuse, trauma, psychosocial adversity, etc.) should be identified and systematically monitored over time for the development of a depressive disorder.

10. GLAD-PC Guidelines: Identification/Surveillance • Targeted screening versus universal screening • Previous history of depression • Family history of mood disorder or other mental illness • Trauma/ongoing conflict • Medical illnesses • Strategies • General questions “How is your mood?” “Have there been changes in your interests?” • Screening tool (handout)

11. GLAD-PC Guidelines: Assessment/Diagnosis Recommendation I: PC clinicians should evaluate for depression in high-risk adolescents as well as those who present with emotional problems as the chief complaint. Clinicians should assess for depressive symptoms based on diagnostic criteria established in the DSM IV or ICD 10 and should use standardized depression tools to aid in the assessment.

12. Signs and Symptoms of Depression • Sadness • Irritability • Low energy/Fatigue • Poor concentration • Low motivation/interest • Sleep disturbance • Change in appetite • Thoughts of death

13. GLAD-PC Guidelines: Assessment/Diagnosis (cont.) Recommendation II: Assessment for depression should include direct interviews with the patients and families/caregivers and should include the assessment of functional impairment in different domains and other existing psychiatric conditions.

14. Overlap Between Manic and Depressive Symptoms Mania Depression • Irritability • Insomnia • Agitation • Impaired concentration • Delusions • Hallucinations • Euphoria • Decreased need for sleep • Increased energy • Racing thoughts • Increased self-esteem (grandiosity) • Lack of interest • Too much sleep • Fatigue • Decreased self-esteem • Suicidal thoughts

15. Overlap Between Manic and ADHD Symptoms Mania ADHD • Irritability • Agitation • Impaired concentration • Increased energy • Impulsivity • Hyperactivity • Increased • speech • Elation • Decreased need for sleep • Racing thoughts • Increased self-esteem (grandiosity) • Delusions • Hallucinations • Hypersexuality • Persistent symptoms • Onset before age 7

16. GLAD-PC Guidelines: Initial Management Recommendation I: PC clinicians should educate and counsel families and patients about depression and options for the management of the disorder. Clinicians should also discuss limits of confidentiality with the adolescent and family.

17. GLAD-PC Guidelines: Initial Management • Follow-up • Reminders • Psychoeducation • What is depression? • What are the treatment options? • The role of sleep/nutrition/stress/social activities

18. GLAD-PC Guidelines: Initial Management (cont.) Recommendation II: PC clinicians should develop a treatment plan with patients and families and set specific treatment goals in key areas of functioning including home, peer, and school settings.

19. GLAD-PC Guidelines: Initial Management (cont.) Recommendation III: The PC clinician should establish relevant links/collaboration with mental health resources in the community, which may include patients and families who have dealt with adolescent depression and are willing to serve as resources to other affected adolescents and their family members.

20. GLAD-PC Guidelines: Initial Management (cont.) Recommendation IV: All management must include the establishment of a safety plan, an emergency communication mechanism should the patient deteriorate, become actively suicidal or dangerous to others, or experience an acute crisis associated with psychosocial stressors especially during period of initial treatment when safety concerns are highest.

21. GLAD-PC Guidelines: Treatment Recommendation I: After initial diagnosis, in cases of mild depression, clinicians should consider a period of active support and monitoring before starting other evidence-based treatment.

22. GLAD-PC Guidelines: Treatment (cont.) Recommendation II: If a PC clinician identifies an adolescent with moderate or severe depression or complicating factors/conditions such as co-existing substance abuse or psychosis, consultation with a mental health specialist is recommended. Appropriate roles and responsibilities for ongoing management by the PC and mental health clinicians should be negotiated. The patient and family should be consulted and approve the roles of the PC and mental health professionals.

23. GLAD-PC Guidelines: Treatment (cont.) Recommendation III: PC clinicians should recommend scientifically-tested and proven treatments (i.e., psychotherapies such as cognitive behavioral therapy or interpersonal therapy, and/or antidepressant treatment such as SSRI’s) whenever possible and appropriate to achieve the goals of the treatment plan.

24. GLAD-PC Guidelines: Treatment • 2 types of evidenced-based psychotherapy • Cognitive Behavioural Therapy (CBT) • Interpersonal Therapy • CBT easier to incorporate into clinical practice • Spend time with friends/socially • Rational thinking • Relaxation strategies

25. GLAD-PC Guidelines: Treatment • Medication efficacy and safety • FDA and Health Canada Warnings • First-line SSRI’s • Fluoxetine 10 mg to 40 mg • Escitalopram 10 mg to 20 mg • Sertraline, Fluvoxamine, Citalopram • Some suggestion of differences among SSRI’s • No monitoring schedule outlined by FDA or Health Canada • Weekly contact for first few weeks • Reviews of side effects (Handout)

26. GLAD-PC Guidelines: Treatment (cont.) Recommendation IV: PC clinicians should monitor for the emergence of adverse events during antidepressant treatment (SSRIs).

27. Management of Major Depressive Disorder in Adolescents • Lack of psychotherapy resources in the community • Prescribing decreased since the 2004 FDA and Health Canada warning • Likely due to both clinician judgment and patient/family preference • Parallel increase in suicides in youth in both US and Manitoba • Only 3% following FDA recommendations and only a small minority seeing patients monthly for first 3 months of initiating medication • Need for greater integration of warnings into clinical practice Linberry et al., 2006; Cheung et al., 2008; Katz et al., 2008;

28. GLAD-PC Guidelines: Ongoing Management Recommendation I: Systematic and regular tracking of goals and outcomes from treatment should be performed including assessment of depressive symptoms and functioning in several key domains: home, school, and peer settings.

29. GLAD-PC Guidelines: Ongoing Management (cont.) Recommendation II: Diagnosis and initial treatment should be reassessed if no improvement is noted after 6-8 weeks of treatment. Mental health consultation should be considered.

30. Reassessment of Diagnosis • Low energy/Fatigue • Nutrition/Exercise, Worries/Anxiety, Anemia • Poor concentration • Attention Deficit Disorder, Stresses/Trauma, Worries/Anxiety

31. GLAD-PC Guidelines: Ongoing Management (cont.) Recommendation III: For patients achieving only partial improvement after PC diagnostic and therapeutic approaches have been exhausted (including exploration of poor adherence, co-morbid disorders, and ongoing conflicts or abuse), a mental health consultation should be considered.

32. GLAD-PC Guidelines: Ongoing Management (cont.) Recommendation IV: PC clinicians should actively support depressed adolescents referred to mental health to ensure adequate management. PC clinicians may also consider sharing care with mental health services where possible. Appropriate roles and responsibilities, and co-ordination of care, should be negotiated between the PC clinician and the mental health specialist.

33. GLAD-PC Toolkit (downloadable from www.gladpc.org) • Screening/assessment instruments • Algorithm/Flow Sheet • Screen for parental depression (i.e., PHQ-9, 2-question screen) • Treatment Choices-Active Support guide, Psychotherapy guide and Medication guide and dosage charts • Fact sheet/family education materials • Self-management tools

34. GLAD-PC Guidelines: Implementation Plans Toolkit development • Pilot testing with family medicine and pediatrics • Modification based on feedback • Slight variations based on different clinician groups, and practice models

35. GLAD-PC Guidelines: Implementation Plans Testing of collaborative care models • Shared care • On-site mental health support • Telephone consultation

36. GLAD-PC Guidelines: Implementation Plans Testing of collaborative care models • Involvement of funding agencies • Development of alternative funding plans • Initial studies to examine feasibility and qualitative data on models • Larger randomized controlled trial to examine changes in patient outcomes

37. Questions/Contact • www.gladpc.org • Dramy.cheung@gmail.com • Other Resources • Mood Disorders Association of Ontario • Ementalhealth.ca