Transcript Severe - CHADIS

Rising incidence of Major Depression
3 million (one episode in past year) 19.5 % females; 5.8% male
Reasons for Increase
• Post 9/11 era of economic and national
insecurity
• Conclusion of 2015 study of social media use
in 13 year olds: “there is no firm line between
their real and online worlds.”
– “We’re the first generation that cannot escape our
problems at all.”
Developmental Trajectory
• Median age of onset; Prevalence
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Anxiety -6 yrs; 32%
Behavior – 11 yrs: 19%
Mood – 13 yrs; 14%
Substance use – 15 yrs 11%
Anxiety & behavioral disorders may be precursors
Bully victimization and cyberbully victimization differentially
predicted depressive symptoms trajectories across
adolescence
– Prevalence of disorders with severe impairment and/or
distress: 22.2%
– 11.2% mood
– 8.3% anxiety
– 9.6% behavior
Suicide – 2nd Leading Cause of Death
(ages 10 – 24)
• 5,500 killed themselves in 2014
• > 2 million attempts
– 90% surprise to parents
• Majority of individuals who die by suicide have
had contact with a healthcare provider within
three months prior to their death
• Often present solely with somatic complaints and
infrequently discuss suicidal thoughts and plans
unless asked directly.
Importance of Identification in Primary
Care
• Under-identified and under-treated in primary care
• Importance of recognizing symptoms:
– Poor concentration, loss of pleasure in activities, and fatigue
can affect school attendance and academic functioning.
– Being irritable, short-tempered, and hard to please (all of
which may be the result of depression) make peer and family
relationships more difficult.
– Feelings of worthlessness can affect self-confidence, which in
turn can affect schoolwork, extracurricular activities, and self
esteem.
• Aches and pains for which there are no medical causes
may be explained
Recommendations for Primary Care
(GLAD-PC; AAP)
• Ask directly about depression and suicide.
• Cannot rely on teens to volunteer information
• Screen yearly for all teens
• Combine depression-specific screening tools with follow-up
clinical interviews including from other informants (e.g.,
parents)
• Reconcile discrepant information--> diagnosis/impairment
assessment
Children at Risk: “closer monitoring”
• Emotional problems
• Frequent somatic complaints
• Depression risk factors
– previous history or family history of depression,
– bipolar disorder or suicide related behaviors,
– substance abuse, other psychiatric illness,
– significant psychosocial stressors
– family crises, physical and sexual abuse and neglect,
other trauma
– history of previous diagnosis of depression or suicidality
Primary Care Screening & Assessment
(GLAD-PC)
Routine Check-UP
CC = Emotional Issue
Screen
Surveillance
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- Depression/+ other MH
Revisit w other
guidelines
Recheck for
depression in F/U’s
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Assessment
1. Dx Tool + r/o Comorbidity
2. Interview Parent & Teen
3. Assess Safety/Suicide Risk
+ Depression/
- Psychotic or Suicidal
+ Psychotic or Suicidal
Crisis/Emergency Services
Mild; Mod.; Severe; +/- Comorbidities
1. Evaluate Safety/plan; 2. Evaluate Severity
3. Patient/Family Education; 4. Severity based Rx Options
Standardized Depression Screening Tools
• Recommended by GLAD-PC (teen administered)
– PHQ-9 modified for teens*
– Kutcher Depression Scale (6 items)*
– Columbia Depression Screen (22 items)
• Others
– Center for Epidemiological Studies Depression Scale for
Children (CES-DC)* (20 items)
– Beck Depression Scale (21 items)
• Available in CHADIS*
• CHADIS waiting room bundle: PHQ-9; PRIUSS-3/15;
CRAFFT; ASQ (Suicide)
MDD Symptoms (PHQ-9)
• 1. Over the last 2 weeks, how often have you been bothered by any of the following problems?
• 9 Symptoms/frequency: Not at all; Several days: More than half the days; Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling/staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television.
8. Moving or speaking so slowly that other people could have noticed. Or the opposite; being s
fidgety or restless that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead or of hurting yourself in some way.
• Impact item: Not difficult at all; Somewhat difficult; Very difficult; Extremely difficult
• 2. If you checked off any problem on this questionnaire so far, how difficult have these
problems made it for you to do your work, take care of things at home, or get along with other
people?
Assessment
• Use diagnostic type tool:
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PHQ-A (depression, anxiety, substances)*
CHADIS – DSM-5 (all DSM + DSM-PC)*
CBCL (7 DSM areas) *
BASC
• *Available in CHADIS
• Interview
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Establish confidentiality (with limits)
May not recognize depressed mood
Distinguish transient depressive responses from depressive disorders
common presenting symptoms: Insomnia, weight loss, decline in
academic functioning, family conflict, as well as other symptoms of
depressive disorders
– Direct interviews with families/caregivers separate from youth
• Symptoms of depression and functional impairment
• Family relationships may also impact on the presentation
• Cultural background can impact the presentation of core symptoms.
DSM Guidelines for Grading Severity Depression
Category
Mild
Moderate
Severe
Number (of
9 MDD) 5-6*
symptoms
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"most"
Severity of
Mild
symptoms
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Severe
Degree of Mild impairment or
functional normal functioning but
impairment with "substantial and
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unusual" effort
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"Clear-cut, observable
disability"
Moderate "have a severity that is intermediate between mild and severe."
*Except consider severe even with "mild" in symptoms if: risk factors: presenting with of
a specific suicide plan or recent attempt; psychotic symptoms; FH of 1st degree relatives
w biploar disorder; or severe impairment (e.g., unable to leave home)
**Impairment > # sx: Severe = >6>/= mild depressive sx & severe impairment
Differential Diagnosis
• Chronic illness with fatigue, altered sleep, appetite
suppression
– But depression is more common with chronic illness
• Substances
• Prescription drug side effects
– phenobarbital, antihypertensives, steroids
– Over the counter drugs containing synthetic narcotics
– Accutane
Co-Morbidities (60 – 80%)
• Persistent Depressive Disorder (Dysthymia)
(“double depression”)
• Adjustment with depressed mood
– less severe, fewer sx, <3 mos,
– after a life stress, (can go on to MDD)
• Other psych disorder
– ADHD; LD; Anxiety; Eating; Substance
Initial Depression Management based on Severity Level
(GLAD-PC)
If Mild
If Moderate
Support + monitoring*
q 1 – 2 wks for 6-8 wks
If Improved
Consider consult to
create plan
If Severe or Co-mordities
Should get consult to
create plan**
If Persistent
Manage in Primary Care
1. Evidence-based meds +/- psychotherapy*
2. Monitor for sx and adverse events (e.g.,
suicidal ideation/mania)
3. Consider consultation
• *Psychoeducation; supportive
counseling; refer for peer support;
• ** Negotiate roles and maintain
contact - consider MCPAP model
Refer
Initial Management
• New onset Mild
Consider period of active support and monitoring before other evidence-based
treatment
– for a predetermined period of time (usually between 6 to 8 weeks)
– this is first line therapy possible in any practice setting with evidence for efficacy
– Not just "watchfully waiting". Should include specific steps such as:
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Schedule frequent visits-weekly or biweekly
Prescribe regular exercise and leisure activities
Recommend a peer support group
Review Self-Management goals
Follow-up with patients via telephone
Provide patients and families with educational materials
– Education of patients and family members (and - when indicated and informed consent
is obtained - teachers and/or peers)
– If no improvement begin specific rx
• Mild Depression with moderate or severe or comorbidities such as substance
abuse, recommend treatment, crisis intervention (as indicated), and mental
health consultation immediately
• Moderate depression with or without comorbid anxiety,
– consider consultation by mental health and/or treatment in the PC setting.
Continued Depression Management based
on Progress after 6 – 8 weeks
Improved
1. Con’t meds 1 yr.
2. Monthly monitor
for 6 mo post
remission
3. Con’t monitor for
6-24 mos
4. Maintain contact
w. Mental Health
Partially Improved
Not Improved*
1. Reassess DX*
2. Consider:
1. Adding med.; Increase dose to max
tolerated; change med*
2. Add therapy
3. Consult mental health
3. Further education; review safety plan;
con’t monitor
First Priority = Safety Assessment and
Planning
• Depressed patients are at an increased risk for suicide
• Period of initial treatment plan is a vulnerable time.
• Ask about suicidal thoughts (e.g., ASQ)
– Asking may help prevent - not promote - suicide.
• Assess that adequate adult supervision and support are available.
• Instruct the supporting adult to remove lethal means:
– firearms, alcohol, prescription and over the counter medications
• Engage the potentially suicidal adolescent so as to:
– Monitor for risk factors for suicide,
– Provide the adolescent with mutually agreeable and available emergency
contacts
• Team approach may be needed to provide quick and consistent follow-up
and increase compliance in suicidal.
– Plan may include: a list of persons who are aware of the adolescents' issues and
will be able to assist if contacted during an acute crisis.
– Consider working with schools (so as not to label a specific individual) to
develop an emergency plan for all students who may experience an acute
suicidal crisis.
Initial Education of Parents and Teens
• De-stigmatize the experience of being depressed.
– Watch for negative reactions of family to teen (i.e., sadness, anger,
denial)
• Educate the patient and family about the:
– Origins
Depression probably results from an innate predisposition coupled with
recent stressors
– Time course:
• Treated depression will likely result in return to regular functioning in weeks or
months.
• Without treatment, depression may last many months or years and is likely to
recur.
• Requires ongoing monitoring
– Treatment options for depression.
• Empower the patient and family to get the help they need
NAMI Handout in CHADIS
Develop specific treatment plan
• General Principles:
• Set specific treatment goals for: home, peer, and school
settings
• For moderate to severe depression or persistent
depressive symptoms, treatment goals may include:
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Regular exercise routine
Adequate nutrition
Regular meetings to resolve issues at home
Consider designating a case manager, in addition to the PCP
for monitoring the teen's clinical status and treatment plan
adherence.
– Document
– Practice registry
Severe: Referrals and Follow-up
• Consider re: need for consultation:
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issues of access and other barriers to care
treatment preferences of patients/families
severity and urgency of the case presentation
physician's level of training and experience
• Establish a plan for communication between primary care and mental
health providers to assure that children don't fall through the cracks.
• Use consent forms- Available in CHADIS
– if both PCP and Mental Health Provider are CHADIS users you can email
[email protected] that written consent has been obtained and
CHADIS reports will be made available to the other party for continuous
correspondence.
– If care manager is available, have them provide telephone follow-up using
guidelines for a comprehensive telephone-based care management system.
• Greater efficacy of shared care models for the management of depression
in the PC setting has been demonstrated in adults and emerging evidence in
pediatrics
• If there is a lengthy waiting list for mental health services, initiate active
support and treatment.
Sequence in Referral Process
• Recognizes need for mental health referral (a clinical process itself).
• Explains reasons for mental health referral and recommends appropriate
level of care and type of mental health services (i.e. inpatient, outpatient;
counselor, psychologist, psychiatrist).
• Determine patient and family agreement for outside care:
– If patient and family are amenable selected MHP based upon a variety of
factors, such as geographic location, insurance coverage, goals of treatment,
and if combined therapy with antidepressants are being used
– May use referral form (See PCP to MHP form), once a MHP is chosen, including
PCP office contact information to facilitate further communication and follow
up. Send form or form can be given to MHP directly by the patient and his/her
parent or guardian.
• Consider providing the MHP with a Release of Information and Report form,
so he/she can communicate basic impressions and recommendations to
PCP
• PCP and MHP together, should:
– carefully define and discuss follow-up roles including the designation of case
co-ordination responsibilities.
Problem Solving Treatments for Primary
Care (PST-PC)
• A psychological treatment for depression:
– tested in adult populations
– may be performed by primary care clinicians or staff who
have been formally trained.
• Based on the finding that depression is associated with
life problems.
• Patients meet with the clinician for four to six 30minute sessions over a 6-10 week period. The focus of
PST-PC involves the following:
– identifying and clarifying problems,
– setting realistic goals and generating solutions, and
– evaluating progress and renewing problem-solving efforts,
when indicated
Evidence-based Psychotherapy
• Evidence in teens with depression
• Individually (the youth alone with a mental health
specialist), in a group (a mental health specialist,
youth, and others with similar problems).
• > ½ respond
• Duration: weekly hour- long counseling session for
8-20 weeks.
• If not noticeably improved after six to twelve weeks
of counseling, should probably add meds
• Not recommended as the only treatment if severe
– E.g., if psychomotor retardation
Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT)
Therapy
Key Components
-Thoughts influence behaviors and feelings, and vice versa. Certain
negative thoughts, e.g., pessimism and self-denigration, evoke negative
feelings
CBT
-Essential elements:
1. increasing pleasurable activities (behavioral activation),
2. reducing negative thoughts (cognitive restructuring), and
3. improving assertiveness and problem-solving skills to reduce
feelings of hopelessness
-Interpersonal problems cause or exacerbate depression and depression,
in turn, may exacerbate interpersonal problems-
IPT
Essential elements:
1. identifying an interpersonal problem area,
2. improving interpersonal problem-solving skills, and
3. modifying communication patterns.
CHADIS Handout
CHADIS Handout
Evidence-based Pharmacotherapy
• Optional indications:
– CBT or IPT not available
– Preferred; sometimes indicated:
• Medication needed:
– severe or persistent depression
– co-morbid anxiety disorders (e.g. panic, separation
anxiety, social phobia, GAD or OCD).
• Prescribing in primary care:
– 25% of US pediatric PC clinicians
– 42% of family physicians have recently prescribed SSRI's
to teens (Rushton, 2000)
Medication Education
• Safety: the FDA's review of the SSRI safety data,
including suicidality
• Side effects: Common side effects associated with
SSRI's
• Administration: The importance of supervision of
medication administration and handling of medication
by adults only.
• Duration: The likely duration of treatment (i.e., 6
months to 1 year after cessation of symptoms)
• Withdrawal: The possibility of withdrawal symptoms if
medication is stopped without medical supervision
Selective Serotonin Reuptake Inhibitors
(SSRIs)
• Fluoxetine is the first-line treatment of depressive disorders in children.
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FDA-approved for depression (and OCD) in children seven years and older.
Multiple successful medication trials
Long half-life (which minimizes adverse effects of poor compliance)
Other SSRIs may be considered "first-line" as well.
• Watch for increased agitation, irritability, or decreased
– If this occurs:
• Discontinuing or decreasing the dose
• Clarify diagnosis and treatment plan
• And/or consultation with a child and adolescent psychiatrist
• Choice of an SSRI can be based on:
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FDA approval for adolescents
Success of prior medication trials
SSRI half-life
Interactions with other medications
Side effect profiles of the different medications
Family history of successful medication treatment
Patient's medical issues
• Effective dosages for antidepressants in adolescents are lower than for adults.
SSRI Titration Schedule
SSRI
Starting Dose* Increments
Max Daily
Dose
Contraindicated
Meds
Fluoxetine
(Prozac)
10mg qd/od** 10-20mg
60mg
MAOIs
Sertaline
(Zoloft)
25mg qd/od** 12.5-25mg
200mg
MAOIs
Citalopram
(Celexa)
10mg qd/od** 10mg
60mg
MAOIs
Escitalopram
(Lexapro)
5mg qd/od**
20mg
MAOIs
250mg
MAOI's,
terfenadine,
astemizole,
pimozide
Fluvoxamine
(Luvox)
25 mg qd/od,
** then bid
5mg
25 mg
Available
Doses
10 mg tablets
10,20,40 mg
pulvules
90mg weekly
pulvule and
liquid form
25, 50, 100 mg
tablets and
liquid form
20, 40 mg
tablets and
liquid form
5, 10, 20 mg
tablets and
liquid form
RCT evidence
for efficacy
Y***
Y
Y
N
25, 50, 100 mg
tablets and
N
liquid form
* Start with lower doses for younger children; **qd = od = every day; ***Fluoxetine is FDA approved.
Monitor for adverse events
• FDA black box warning re use of these medications in children
and adolescents recommendation: for close monitoring:
• The exact wording = "all pediatric patients being treated with
antidepressants for any indication should be observed closely for
clinical worsening, suicidality, and unusual changes in behavior,
especially during the initial few months of a course of drug
therapy, or at times of dose changes, either increases or
decreases."
• "Ideally, such observation would be with family members or
caregivers during the first 4 weeks, at bi then weekly visits for
the next 4 weeks, including at least weekly face-to-face contact
with patients or their parents then at 12 weeks, and as clinically
indicated beyond 12 weeks. Additional contact by telephone may
be appropriate between face-to-face visits."
• Expert opinion suggests that telephone contacts may be just as
effective as face to face and (Glad PC) but clinicians should
attempt to follow these FDA guidelines.
Ongoing Management
• Systematic and regular tracking of goals and outcomes
• Assessment of depressive symptoms and functioning in
several key domains: home, school, and peer settings should
include:
– Improvement in functioning status (home, school, peers)
– Resolution of depressive symptoms.
• Follow-up visit should be within 1 week of start of meds.
• Content at every visit should ask about:
– ongoing depressive symptoms,
– risk of suicide
– possible adverse effects (consider use of specific side effect scalessee clinician text: side effects of antidepressants)
– adherence to treatment,
– new or ongoing environmental stressors.
Finding the optimal dose
• First find the optimal dose: benefits outweigh
side effects.
• Then weekly follow-up assessing response to
the medication optimizing:
– Changes in severity of symptoms
– Changes in impairment
• Side effects
Dosing
• Dosing is adequate when:
– significant changes occur in target symptoms and scores
on baseline assessment instruments
– severity scales improve
– side effects are absent or tolerable
• Increase dosage when:
– after (4-6 weeks) with little or no change seen in target
symptoms or baseline assessment scale scores or
severity
– and no apparent intolerable side effects.
CHADIS Handout
Side effects of SSRI's:
• Common
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Dry mouth
GI: Constipation or Diarrhea
Sweating
Sleep disturbance
Sexual dysfunction
Irritability
"Disinhibition" (risk-taking behaviors, increased impulsivity, or doing things that
the youth might not otherwise do)
Agitation or jitteriness
Headache
Appetite changes
Rashes
• More serious side effects include the following:
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Serotonin syndrome (fever, hyperthermia, restlessness, confusion, etc.)
Akathisia
Hypomania
Discontinuation syndrome (dizziness, drowsiness, nausea, lethargy, headache)
Maintaining Medication
• Continue on medication for 6 – 12 mos following sx
cessation
• Two or more years of maintenance may be needed
to prevent relapse.
• Monthly follow-up appointments once stabilized to
check efficacy
• Each follow-up should evaluate target symptoms,
adverse reactions & medication compliance at each
follow-up visit
• Adolescent and parent symptom checklists every 3
months.
Stopping Medication
• Taper slowly to avoid withdrawal
– Except fluoxetine
• Close follow-up is recommended for at least 2-3
mos, the time of greatest risk of relapse
• Monitor on a monthly basis for 6 -12 months after
full resolution of symptoms
• Length of monitoring after treatment stoppage - 2
yrs
• Indications for mental health consultation:
– psychosis, suicidal or homicidal ideation
• new or worsening of comorbid conditions
Computerized Interventions for
Depression in Adolescents
• CBT models
– Some benefit
– Poor adherence
• EMRs (ecological momentary interventions)
• JITAIs (just-in-time-adaptive interventions
– proactively prompt individuals to interact through
instantaneous communication (e.g., texting feedback based
on mood and context; sensors)
– As adjunct – not replacement to an empathic human being
Comparing Interventions
• School-based interventions
– targeted group-based interventions
– cognitive behavioral therapy
• Digital platforms promising
• Exercise reducing depression score
• Psychological therapy compared to antidepressants
have comparable effect on remission, dropouts, and
depression symptoms.