Transcript Depression: How to diagnose and how to start treatment

Depression: How to
diagnose and how to start
treatment
Tamara Helfer, MD
Child and Adolescent Psychiatrist
St. Luke's Center for NeuroBehavioral Medicine
Learning Objectives:
How to recognize depression, even in children and
adolescent
Understand treatment options
Improve patient care
Learn how to get reimbursed for screening tools
Depression per DSM-5
 5 or more for 2 week period:
 Depressed mood most of the day (in children/adolescents can be irritable
mood)
 Marked diminished interest/pleasure in almost all activities
 Decrease or increase in appetite nearly every day (in children failure to make
expected weight gain)
 Insomnia or hypersomnia
 Psychomotor agitation or retardation
 Fatigue or loss of energy
 Feelings of worthlessness or inappropriate guilt
 Diminished ability to think/concentrate
 Recurrent thoughts of death or SI
Depression Facts in
Children/Adolescents
 About 5 % of children/adolescents in general population suffer from
depression
 Increased risk:
 Stress
 Experienced loss
 ADHD
 Learning disorder
 Conduct disorder
 Anxiety
 Depression runs in families
Depression in children/adolescents may
differ from the behavior of depressed adults
Adult Similarities
Child Specific
Depressed Mood
Persistent boredom, Low energy
Decreased Interests/Activities
Social isolation/Poor communication
Hopelessness
Extreme sensitivity to rejection/failure
Low Self Esteem/Guilt
Increased irritability, anger
Major change in sleeping/eating
behaviors
Frequent complaints of physical
illnesses (HAs and stomach aches)
SI or self destructive behavior
Frequent absences from school or
poor performance in school
Poor concentration
Talk of or efforts to run away from
home
Depression…
 A child who used to play often with friends and now spends most of the
time alone and without interests
 Things that were once fun now bring little joy
 May start causing trouble at home/school
 Seems more irritable
 A lot of times drug/alcohol use starts as a way to start trying to feel better
 Because the child/adolescent may not seem sad, parents/teachers may
not realize that the troublesome behavior is a sign of depression
 When asked directly, these children can sometimes state they are unhappy
or sad
 WE NEED TO ASK!!!
TADS Study
 Treatment for Adolescents with Depression Study (TADS)
 Funded by the National Institute of Mental Health (NIMH), and published in 2004
 Examined three different treatments for adolescents with moderate to severe
depression:
 1. Prozac (Fluoxetine) vs Placebo
 2. CBT (Cognitive Behavioral Therapy) vs Placebo
 3. Prozac + CBT vs Placebo
 12 week long study
 All showed some improvement, but overall the combined treatment resulted in
the better functioning and quality of life
 It is the preferred treatment for speedier responses across a broad range of
outcomes such as remission and recovery of function.
Treatment
 Early diagnosis and treatment are essential!!!
 Early intervention has shown to improve outcomes
 As the TADS showed, combined treatment (therapy + medication) is the
most effective for speedier responses, for remission, and for recovery of
function
 About 60 percent of children and adolescents will respond to initial
treatment with medication (SSRI)
What if no treatment…
 Untreated depression can last 6-9 months (an entire school year for most kids)
 No treatment can mean serious consequences
 Increases risk of:
 Substance abuse
 Eating disorders
 Adolescent pregnancy
 Suicidal thoughts
 More ongoing problems at school/home/friends
 Without treatment, the child runs the risk of developing a chronic and more
difficult to treat depression
 Once a child has one period of depression, they are at greater risk to get
depressed again
Medications
 1st line: SSRIs
 Prozac (Fluoxetine): >7 for OCD, >8 for MDD
 Celexa (Citalopram): >12 for depression
 Lexapro (Escitalopram): >12 for depression
 Zoloft (Sertraline): >6 for OCD
 2nd line: SNRIs
 Cymbalta: >7 for GAD
 Effexor: off label for anxiety/depression
 A lot of meds will be off label!
How long to treat?
 Per the National Institute of Mental Health study, children and adolescents
should stay on their meds for at least 6-9 months AFTER remission
 This is to help prevent relapse
 Go slowly, closely monitor, and look for signs of relapse
 Be more cautious with those who have:
 A family history of mood disorders
 Severe and complex episodes of depression
 A slow and difficult response to treatment
 A history of chronic depression
 Multiple depressive episodes may benefit from continuing treatment for 1-2
years or more.
Screening Tools
 AAP, APA, or AACAP “sanctioned”
 NOT a diagnosis (but they help…A LOT)
PHQ-9 Modified for Adolescents
 9 symptom inventory of depression
 Scoring:
5
10
15
20
Mild
Moderate
Moderately
Severe
Severe
 Self-rated
 In consideration of the last 14 days
 For ages 7-17 consider the CDI (but it will cost $)
Reimbursement:
96110
Genetic Component
 Depression runs in families
 Children with one depressed parent are 3x more likely to have MDD than
children of non-depressed parents
 In children exposed to substantial stress:
 Those with mother’s who were depressed did worse than those with just the stress
 We need to treat parents!!!
Resources
 AACAP (American Academy of Child and Adolescent Psychiatry)
 DSM-5
 NIMH (National Institute of Mental Health)
 The Use of Medication in Treating Childhood and Adolescent Depression:
Information for Patients and Families - Prepared by the APA and the AACAP
in consultation with a National Coalition of Concerned Parents, Providers,
and Professional Associations
 PHQ9: as endorsed by APA/AAP; Validated by Richardson, et.al.:
Evaluation of the Patient Health Questionnaire-9 Item for Detecting Major
Depression Among Adolescents. Pediatrics; 2010 Dec; 126(6): 1117-1123
THANK YOU!!
Questions?