Transcript Depression & Adolescents-Dr Daviss

Pediatric Depression and Suicide:
An Update for School Nurses
W. Burleson Daviss, MD
Dept. of Psychiatry
University of Texas Health Science Center
at San Antonio
Objectives
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Learn about burdens associated with
pediatric depression and suicide
Learn about strategies for assessing pediatric
depression
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Genetic and social risk factors
Clinical signs, comorbidity, differential diagnosis
Assessment strategies in a school-based setting.
Discuss treatment options for pediatric
depression (providing essential information
for school nurses).
Symptoms of Depression-SIGECAPS:
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Sleep problems
Interests decreased
Guilty, worthlessness
Energy problems
Concentration problems
Appetite problems
Psychomotor activity problems: agitation or
slowing
Suicidal thoughts or behaviors
Types of Pediatric Depression
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Major Depression: sad-irritable moods or
decreased interests, + 4 other symptoms, 2
weeks duration, impairing
Minor Depressions:
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Dysthymia: 2+ symptoms, 1 year duration
Adjustment disorder with depression: fewer sxs
and shorter duration, response to stress
Depressive disorder not otherwise specified
Bipolar depression
Mania Mnemonic
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Markedly elevated or irritable moods and
3-4 GR:RAPID symptoms:
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Grandiosity
Racing thoughts
Reckless pleasure-seeking behavior
Activity increased (goal-directed)
Pressured speech
Insomnia: decreased need for sleep
Distractibility
Bipolar Disorders
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Must have had at least 1 manic or nearmanic (hypomanic) episode
Manic episodes must last 4+ days with
markedly irritable or elated moods
Depressed symptoms often last longer than
manic symptoms
Bipolar Disorders in Children
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Rapid cycles
Mixed episodes
Often occur with psychotic symptoms
Positive family history of bipolar disorder
Prevalence in Youths
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MDD: 2% in children, 8% in adolescents
20% by the end of adolescents have had at
least one MDD episode
Bipolar disorder: 1-2%
20-40% of patients with MDD become
bipolar
Morbidity/Mortality of Unipolar
and Bipolar Mood Disorders
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Bipolar more severe risk than unipolar
Both typically recur, with worsening severity
Both have serious long-term impact:
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Scholastic
Interpersonal
Occupational
Substance abuse
Legal problems
Suicide
Suicide: 3rd Leading Cause of Death
in Youths Ages 15-19
— U N I T E D S T A T E S, 2001 —
CAUSE
# OF DEATHS
Accidents
Homicide
Suicide
Cancer
Heart Disease
Congenital Anomalies
Chronic Lower
Respiratory Disease
Stroke
Influenza and Pneumonia
Blood Poisoning
Anderson & Smith 2003
6646
1899
1611
732
347
255
74
68
66
57
1599
C.E14
Environmental factors
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Traumatic exposure and other adverse life
events
Family conflicts
Parental stress
Peer problems
School problems
Are these a cause or an effect?
Heritability
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How much of the disorder is due to inherited,
genetic factors (Nature) as opposed to
environmental factors (Nurture)?
Genetic Factors
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Depressive disorders: 40% heritability
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Bipolar disorders: 75% heritability
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3X higher risk of depression in immediate family
8X higher risk of bipolar disorder in immediate
family
3X higher risk of depression in immediate family
Family members of bipolar patients more
likely to have unipolar than bipolar moods.
Pediatric Depression:
Challenges of Assessment
Differential diagnoses:
Anxiety Disorders
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Separation anxiety: child fearful anticipating
separation from parent, clingy, school
avoidant
Social phobia: reluctant to interact with peers
or perform because of fear of embarrassment
Differential diagnoses:
Anxiety Disorders, continued
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Obsessive compulsive disorder: repetitive thoughts
or behaviors, anxious/agitated when not able to do
these, distressing and time consuming
Panic disorder: intense panic attacks, brief and must
sometimes occur without a specific trigger
Generalized anxiety disorder: pervasive worries
multiple things, physical complaints (insomnia,
muscle tension, restlessness), irritability
Differential Diagnoses:
Disruptive Disorders
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Irritability limited to specific situations
involving authority figure
Oppositional disorders: child angry, irritable &
defiant with adults’ limit-setting, deliberately
breaks rules, avoids accepting blame
Conduct disorder: more severe DBD, lying,
stealing, vandalism, aggression to animals or
people
Differential Diagnosis: ADHD
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Problems in 1+ domains of symptoms
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Inattention: distractibility, disorganization,
trouble listening
Hyperactivity/impulsivity: restlessness, and
the “butt-in-skies”
Best discriminators: depressive
cognitions > somatic/vegetative sxs
Comorbid Disorders
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Most mood disorders co-occur with some
other disorders (comorbidity)
Comorbid disorders occur first
Complicate recognition of mood disorder
Reduce effectiveness of treatments
Worsen psychosocial outcomes
Assessment Strategies for
Pediatric Depression
Diagnostic Work Up: History
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Review history of psychiatric symptoms
Review medical problems
Review family’s mental health history
Assess child’s function at school, with peers,
and at home
Review stressors that may be contributing
Rating Scales
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Allow collection of data from multiple raters
(child, parent, teachers)
Screen for depressive symptoms and other
diagnoses
Help to monitor course of mood disorder and
response to treatment
Rating Scales: General Scales
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Child Behavior Checklist, Teacher’s Report
Form, Youth Self Report
Child and Adolescent Symptoms Inventory,
Adolescent Symptom Inventory
Vanderbilt Parent and Teacher Rating Scales
(see handout)
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Simple, easy to use and score
Good screen for disruptive behaviors
Spanish version available
Available free on the web:
http://devbehavpeds.ouhsc.edu/rokplay.asp
Vanderbilt Scales: Scoring
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Scoring guide on handout
Count the number of symptoms rated 2 or 3 in
various sections
Symptoms clumped by disorders
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ADHD: #1-18
ODD: #19-26
CD: #27-40
Anxious/depressed: 41-47
Functional assessment section: #48-55, count the
performance items rated 4 or 5
Rating Scales for Depression
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Beck Depression Inventory
Children’s Depression Inventory
Mood and Feelings Questionnaire (see
handout)
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Parent- and child- versions, long and short forms
Simple wording and structure
Available free on web: http://devepi.mc.duke.edu
Spanish version for parents developed by our
group
Mood and Feelings
Questionnaire: Scoring
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Useful to combine both parent and child
ratings to see if there are at least 5 symptoms
of depression reported as “True”
Scores suggestive of possible major
depression)
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Scores on long version > 24
Scores on short version > 7
Diagnostic Work Up:
Mental Status Exam (MSE)
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Activity level
Spontaneity
Eye contact
Affect
Mood
How do you feel talking to this kid?
MSE: Thought Content
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Self esteem
Hopelessness
Helplessness
Delusions
Hallucinations
Suicidal thoughts or behaviors
Assessing for Suicide
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Ask about suicide, and document you did
Use matter of fact questions:
“Sometimes kids with these sorts of problems
may feel like they’d be better off if they were
dead. Do you ever feel that way?”
“Have you ever thought about killing yourself?”
“Have you thought of ways you could do it?”
“What would make you more (or less) likely to
do it?”
Assessing Suicide Risk
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Current mental health problems?
Positive and negative environmental factors?
Past history of suicide attempts?
Does the child have current intentions to
suicide?
Lethality of methods considered?
Availability of methods considered?
Are there guns at home?
Treatment
Two Main Treatment Options
Psychosocial
 Pharmacological
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Psychosocial Treatments
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Supportive therapy
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Cognitive behavioral therapy
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Educate child and family, address contributing
stressors, refer for assessment and treatment
Depression result from cognitive distortions that
can be corrected with training and practice
Interpersonal therapy
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Uses the issues that come up in relationship with
therapist to help child to cope more effectively
Antidepressants:
Selective Serotoninergic Reuptake
Inhibitors (SSRIs)
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Fluoxetine (Prozac): FDA-approved pedi dep,
well tolerated, slow onset of effects, good for
noncompliant patients
Sertraline (Zoloft): approved for pedi OCD, wider
dose range, some GI side effects and activation
Citalopram (Celexa), Escitalopram (Lexapro):
often well-tolerated and effective; faster acting?
Fluvoxamine (Luvox): approved for pedi OCD,
more drug interactions, less well tolerated
Paroxetine (Paxil): No longer recommended in
pediatric age range, withdrawal problems
Treatment of Adolescents with
Depression Study (TADS)
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NIH-sponsored study of adolescents with
major depression
Compared fluoxetine, cognitive behavioral
therapy, and combination treatments versus
placebo
Antidepressants were more effective than
therapy, especially for severe depression
Combination therapy more effective and safe
CDRS: Adjusted Means (ITT)
Mean CDRS Score - Adjusted
60
COMB
50
FLX
CBT
PBO
40
30
Baseline
Week 6
Week 12
Stage I Assessments
TADS Team (2004), JAMA 292: 807-820
Non-SSRI Antidepressants:
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Bupropion (Wellbutrin): noradrenergic &
dopaminergic, help pedi ADHD; risk of seizures
Mirtazapine (Remeron): Useful for insomnia
Duloxetine (Cymbalta): serotonin &
noradrenergic effects
Venlafaxine (Effexor): no longer recommended
because of withdrawal symptoms
Tricyclics: desipramine, imipramine, nortriptyline;
helpful for insomnia and enuresis but not pedi
depression; cardiovascular risks require ECG &
plasma levels, fatal in overdoses
Depressed
Child or
Teen?
Those who qualify will
receive:
 Interview and Assessment
 Physical Exams
 Comprehensive Lab Analysis
 Medication
 Resource Referral
Compensation available
Continued care if applicable
Call
At the University of Texas
Health Science Center at San
Antonio, we are conducting a
clinical research study using
an investigational medication
bupropion for depression in
adolescents ages 11-18
weighing at least 66lbs.
Symptoms include:
• Sad or irritable mood
• Lack of concentration in
school
•Loss of interest or pleasure
•Changes in appetite or weight
• Fatigue or loss of energy
• Feelings of worthlessness
• Feelings of hopelessness
•Sleep Problems
us at 210-562-5400 for more information
FDA “black box” warning for
Antidepressants, October 2004
Higher suicidality in first weeks on
antidepressants: 4% on antidepressant
medication vs. 2% on placebo
 Applies to all antidepressants in all age
groups
 Need close follow-up early for emerging
suicidal thoughts, worsening mood or
other intolerable side effects
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Rate per
100,000
Why Use Antidepressants At All?
US Epidemiological Studies, Ages 15-24
Anderson 2002, CDC Wonder 2003, USDHEW 1956, Vital Statistics U.S. 1954–1978
C.E16.XX
2-Years After Black Box…
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~10% drop in antidepressant prescriptions
to adolescents from 2004 to 2005
~20% increase in adolescent suicide rates
in the US (from 7.3 to 8.2 per 100K)
Hamilton et al. (2007), Annual summary of vital statistics:
2005. Pediatrics 119(2):345-359
David Brent, MD:
“The risk of emergent suicidality in
children and adolescents receiving
SSRIs is real-- but small.”
 Antidepressants help many more
people than they hurt
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Brent DA (2004), N Engl J Medicine 351(16), p 1601
School Nurse’s Potential Role
in Monitoring
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Weekly assessments, especially early in
treatment for new or worsening symptoms:
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Suicidal thoughts or behaviors
Insomnia
Agitation or irritability
Depressed moods or mania
Communication with the prescribing
physician if there are any concerns
Dr. Brent:
“The Risk of Doing Nothing”
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“Families and clinicians must find the
right balance between the risk of
suicidality and [the] greater risk …that
lies in doing nothing.”
Brent DA (2004), N Engl J Medicine 351(16), p 1601
Summary
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Pediatric depression a potentially devastating
problem, if undiagnosed or untreated
We’ve reviewed risk factors, signs and
symptoms of pediatric depression and suicide
We’ve discussed strategies for assessment
and treatment, especially in school setting
School Nurses’ Key Role
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Identification of children at risk for depression
and/or suicide
Offering education and support to children,
parents, and staff at schools
Helping families to weigh risks/benefits of
various treatments and to follow through
Helping clinicians to monitor children’s
response to treatment
Potential Resources
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Web-pages for parents:
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www.aacap.org
www.nami.org
www.moodykids.org
www.wpic.pitt.edu/research/CARENET/
Web pages for clinicians
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www.moodykids.org
www.wpic.pitt.edu/research/CARENET/
Thanks!!!
Appendices:
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Vanderbilt Teacher’s Rating Scale
Vanderbilt Parent’s Rating Scale
Vanderbilt Parent’s Rating Scale– Spanish
Version
Child Mood and Feelings Questionnaire
Parent Mood and Feelings Questionnaire
Parent Mood and Feelings Questionnaire-Spanish Version
Study flyer for UTHSCSA Depression Trial