Adolescent Major Depressive Disorder (MDD)

1. AdolescentMajor Depressive Disorder(MDD) www.Dreamstime.com 1345216

2. Fast Facts Adolescent Depression • Adolescence = puberty to mid-twenties • Affects approx. 6-8% of adolescents • Most experience 1st episode between 14-24 yrs old • Youth onset usually = chronic condition • Substantial morbidity • Poor economic/vocational/interpersonal/health outcomes • Increased mortality • Suicide • Other long term chronic illness: diabetes, heart disease, etc.

3. Fast Facts Adolescent Depression • Early identification & early effective treatment • Decreases short-term morbidity • Improves long-term outcomes • Decreased mortality www.freedigitalphotos.netby Zirconicusso

4. Depression Screening Question Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? • If YES – consider a depressive disorder • Apply the KADS evaluation

5. Key Steps for Treatment of MDD in Adolescents • Identification of youth at risk for MDD • Screening & diagnosis in the clinical setting • Treatment template • Suicide assessment • Contingency planning • Referral flags www.dreamstime.com 310430

6. Step 1: Major Depressive Disorder in Youth Risk Identification Table

7. If Youth is High Risk… • Educate • About risk of familial mental disorders • Record • Family history of mental disorder • Agree • On a ‘clinical review’ threshold • Urgent and emergency clinical reviews (re: suicide ideation) • Arrange • A standing ‘mental health checkup’ • 15 minutes each 3 – 6 months • Use KADS tool during checkups www.freedigitalphotos.netby Ambro

8. If Youth is High Risk… • Check for patterns • Declining grades • Frequent lates or absences • Confidentiality & informed consent • Both young person and parents/guardian(s) involved • Easier for youth to access care • Easier for parents to know what to expect www.dfreeigitalphotos.netby Idea Go

9. Methods for Clinical Screening& Diagnosis Kutcher Adolescent Depression Scale (KADS-6) Screen at clinical contacts Including contraception & sexual health visits • Explain purpose of test • & give feedback on results www.dreamstime.com ID:983365

10. Distress vs. Disorder

11. Clinical MDD Screening in Primary Care Who to Screen? Refer to Risk Identification Table Adolescents with: Risk factors Persistent low mood • Recent onset Academic problems/failure Substance misuse Suicidal ideation Stockxchng ID: 63460_4774

12. Assessment Tool Kutcher Adolescent Depression Scale (KADS) • Self-reporting instrument • For diagnosis and monitoring • Scoring information included • KADS score 6+ = clinical depression suspected • Suggests a possible diagnosis • Use as a guide for further evaluation

13. KADS Score of 6+ 1st appointment • Discuss issues in youth’s life & environment • Use TeFA – Teen Functional Activities Assessment • Assists in determining impact of depression • Problem solving assistance • “Supportive rapport” • Use PST – Psychotherapeutic Support for Teens as a guide Strongly encourage and prescribe: Regulated Eating Exercise Positive Social Activities Regulated Sleep

14. KADS Score of 6+ 1st appointment (continued) • Screen for suicide risk • Use TASR – Tool for Assessment of Suicide Risk • ‘Check-in’ 3 days following initial appointment • Via telephone (3 – 5 mins.), text message or e-mail • If problems continue, book appointment ASAP www.freedigitalphotos.netby Zirconicusso

15. KADS Score of 6+ 2nd appointment • Mental health checkup • 15 – 20 minutes • 1 week from first visit • Include: KADS, TeFA, PST • Monitor suicide risk 3rd appointment • Mental health checkup • 15 – 20 minutes • 1 week from 2nd mental health checkup • Include: KADS & TeFA • Monitor suicide risk www.freedigitalphotos.netby Nutdanai Apikhomboonwaroot

16. Don’t Get Overwhelmed!! Use the tools Address important issues Three -15 minute office visits Use KADS routinely Suicide intent/plan/attempt = Emergency Mental Health Assessment Dreamstimefree836493

17. MDD Highly Probable if… • KADS scores remain at 6+ • For over 2 weeks • At each of the three assessment points • Suicidal thoughts or self harm behaviors • School, family or interpersonal functioning declines • Assess using TeFA • If above occurs, on 3rd visit complete KADS-11 item • Five or more items score 2+ = diagnosis of MDD • Initiate treatment plan

18. If KADS is 6 or greater or TeFA shows decrease in function – proceed to steps 2 and 3 Visit 1 KADS TeFA Use PST and MEP If KADS < 6 and TeFA shows no decrease in function – monitor again (KADS, TeFA) in two weeks – advise to call if feeling worse give instructions to call if suicide thoughts or plans or acts of self-harm occur CONTACT Phone, Email or Text If KADS remains > 6 or TeFA shows decrease in function – proceed to steps 4 and 5 Visit 2 KADS TeFA Use PST and MEP If KADS < 6 and TeFA shows no decrease in function – monitor again (KADS, TeFA) in two weeks – advise to call if feeling worse – give instructions to call if suicide thoughts or plans or acts of self-harm occur. CONTACT Phone, Email or Text Visit 3 If KADS remains > 6 or TeFA shows decrease in function – proceed to diagnosis (KADS 11) and treatment KADS TeFA Use PST and MEP If KADS < 6 and TeFA shows no decrease in function – monitor again (KADS, TeFA) in two weeks – advise to call if suicide thoughts or plans or acts of self-harm occur

19. Provide Information • Determine what is known already • Identify areas of misinformation • Identify gaps in knowledge & provide information • Be knowledgeable, realistic, clear & helpful • Provide written materials /websites for self study • Many think taking meds will lead to addiction • Discuss anticipated duration of medication use • First episode = 6 – 9 months after they get well • Discuss how meds will impact lifestyle • Light alcohol use is usually ok; can drive with SSRI

20. Creating a Supportive Environment • Compassionate & non-judgmental attitude • Active listening • Eye contact, verbal/non-verbal cues • Clarification • “Help me understand”… • Emotional identification • “It seems you are feeling frustrated”... • Do not jump to conclusions • You are likely to be wrong • ASK, if you don’t understand • If you don’t know the answer – admit & find out www.freedigitalphotos.net by Idea Go

21. Monitoring and Intervention Tools: Depression Monitoring • CGI • TeFA • TASR-A • KADS (6 item; 11 item) Interventions (these do not replace medications or psychotherapies) • PST • MEP

22. Screening for Suicide Risk Risk Factors: • History of suicide attempt or self harm • Presence of Depression • Hopelessness • Family history of suicide • Family history of a mental disorder • Especially mood disorders • If one or more are identified use Tool for Assessment of Suicide Risk in Adolescents (TASR-A) www.freedigitalphotos.netRisk Blocks by jscreationzs

23. Additional Psychosocial Interventions CBIS Depression CBT/IPT tools • Evidence based psychotherapies available (CBIS) • Application recommended – manual provided • Can be implemented at anytime during the process • Education about medications should be added www.freedigitalphotos.net by Idea Go

24. Dealing with Depression

25. A tool like KAD-6 is tangible and helps us and the young person in front of us streamline the conversation to an extent • (perhaps relieves some anxiety for us too)

26. KADS-6

27. Table Discussion • How can these tools fit into GP practice workflow? What about applicability to school or other practice environments? (for example screening tools) • How can other team members use the information from these tools? How can information from other environments be used to complete them? • How can team members in non-providers roles contribute to administration and completion of these tools?