Transcript Adolescent Depression in the PC Setting: Treatment

Managing Adolescent
Depression in Primary Care
Learning Objectives
• Identify treatment components of the AAPapproved Guidelines for Adolescent Depression –
Primary Care (GLAD-PC)
• Select treatment plans that match MDD severity
• Summarize evidence-based treatments for
adolescent MDD
• Describe clinical recommendations when
selecting and using SSRI’s with adolescents
• Review safety planning, assessing suicide risk,
and discussing the FDA boxed warning
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Agenda
• Review treatment of adolescent depression in
PCP settings using the GLAD-PC treatment
recommendations
• Review and apply GLAD-PC flow chart for
adolescent MDD treatment to Jennifer and David
• Peer practice: 1. Safety planning 2. Suicide risk
assessment 3. Discussing Boxed Warning with
parents
• Expert panel discussion on treating pediatric
depression
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GLAD-PC Guidelines:
Initial Management
• Educate and counsel families and patients about
depression and treatment options (Pages 102110).
• Develop a treatment plan with patients and
families with specific goals in key areas of
functioning including home, peer, and school.
• Establish collaboration with mental health
resources in the community and with other
patients and families.
See www.glad-pc.org for entire GLAD-PC toolkit
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GLAD-PC Guidelines:
Treatment
• Categorize current depressive episodes into
one of three levels based on assessment tools
and your clinical judgment (See p. 53 for
definition and 57-64 for tools)
–Mild depression
–Moderate depression
–Severe depression
See www.glad-pc.org for entire GLAD-PC toolkit
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GLAD-PC Guidelines
(See next slide in Participant Book)
• Mild (Specific info: patient education / referral /
follow-up)
– Consider a period of active support and monitoring before
starting other evidence-based treatment.
• Moderate
– Consider starting an SSRI or an Evidence Based
Psychotherapy (EBP)
• Severe
– SSRI’s and EBP are optimal treatment
• Complicating factors/conditions (e.g. co-existing
substance use/abuse, self-injury, suicidal ideation (SI))
– Consider MH referral or hospitalization
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CLINICAL ASSESSMENT FLOWCHART
GLAD-PC
Preparation for Managing Depression in Primary Care
Preparation through increased training, establishing mental health linkages, and increasing the capacity
of practices to monitor and follow-up with patients with depression.
(Guidelines for Adolescent
Depression – Primary Care), p. 16
Youth presents to clinic for urgent care
or health maintenance visit
See www.GLADPC.org for
complete toolkit, 1-151 pgs
Youth or family presents with emotional
issues as chief complaint.
Early Identification
Systematically identify highrisk youth
1) Stop assessment
2) Repeat surveillance as
needed
If low risk
If high risk or presenting with emotional issues as
chief complaint
1)
2)
3)
1. Refer to other treatment guidelines;
2. Evaluate for depression at future visits
3. Book for follow-up visit.
Assessment
Assess with systematic depression assessment tool
Interview patient and parent to assess for depression and
other psychiatric disorders with DSM-IV or ICD10 criteria
Assess for safety/suicide risk
Evaluation Negative for
Depression, but positive for
other MH conditions
Evaluation Positive for
Depression, but not
psychotic or suicidal
If psychotic or suicidal
Refer to Crisis or
Emergency Services
(may include
subsequent referral to
inpatient treatment)
Evaluation Positive for Depression: MILD, MODERATE, SEVERE, or Depression with
COMORBIDITIES
1. Evaluate safety and establish safety plan.
2. Evaluate severity of depression symptoms (See a).
3. Patient/Family Education (See b).
4. Develop treatment plan based on severity-review diagnosis and treatment options with patient/family.
a See
Toolkit page_ for definition of mild, moderate, and severe depression. Please consult toolkit for methods
available to aid clinicians to distinguish between mild, moderate, and severe depression.
Provide Psychoeducation , provide supportive counseling, facilitate parental & patient self-management, refer for
peer support and regular monitoring of depressive symptoms and suicidality.
b
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See WkBk H 1.0
CLINICAL MANAGEMENT FLOWCHART
If *Mild Depression
If *Moderate Depression
Consider consultation by
mental health to determine
management plan.
Active support & monitoring for 6-8
weeks (every 1-2 weeks) (Seea )
If *Severe Depression or Comorbidities
Should consider consultation
by mental health to determine
management plan.
If Persistent
GLAD-PC
(Guidelines for Adolescent
Depression – Primary Care),
p. 17
See www.GLADPC.org for
complete toolkit, 1-151 pgs
a
If Improved
Manage in Primary Care
1. Initiate medication and/or therapy in primary care (see a)
with evidence-based antidepressant and/or
psychotherapy.
2. Monitor for symptoms and adverse events (see c).
3. Consider ongoing mental health consultation.
If Partially Improved
1.
2.
Refer to Mental Health if Appropriate
(see a,b)
If Not Improved
If Partially Improved After 6 –8 Weeks
Consider
• Adding medication if have not already; increasing
to maximum dosage as tolerated if already on
medication
• Adding therapy if have not already
• Consulting with mental health
Provide further education, review safety plan (see a),
and continue ongoing monitoring
1.
2.
3.
If Not Improved After 6-8 Weeks
Reassess diagnosis
Consider:
• Adding medication if have not already; increasing to
maximum dosage as tolerated if already on
medication; changing medication if already on
maximum dose of current medication
• Adding therapy if have not already
• Consulting with mental health
Provide further education, review safety plan (see a),
and continue ongoing monitoring
If Improved
If Improved After 6-8 W eeks
1.
2.
3.
Continue medication for 1 year after full resolution of symptoms (based on adult literature). AACAP
recommendation recommends monthly monitor for 6 months after full remission.
Continue to monitor for 6-24 months with regular follow-up whether or not referred to mental health.
Maintain contact with mental health if such treatment continues.
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Psychoeducation,
supportive counseling,
facilitate parental & patient
self-management, refer for
peer support and regular
monitoring of depressive
symptoms and suicidality.
b Negotiate roles/
responsibilities between
primary care and mental
health, and designate case
co-ordination
responsibilities. Continue to
monitor in primary care after
referral. Maintain contact
with MH
c Professionals should
monitor for changes in
symptoms and emergence
of adverse events such as
increased suicidal ideation,
agitation or induction of
mania. For monitoring
guidelines please refer to
guidelines/toolkit.
See WkBk H 1.1
Evidence Based
Psychotherapies for Depression
• Cognitive Behavioral Therapy (CBT)
• Interpersonal psychotherapy- some
evidence supporting role in pediatric
depression
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What about the
antidepressant medications?
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Treatments for Depression
• Pharmacotherapy
• Fluoxetine (Prozac)--FDA approved for pediatric
patients 8-18 years of age
• Escitalopram (Lexapro)--FDA approved for
adolescents 12-17 years of age
• Psychotherapy: Cognitive Behavioral Therapy (CBT)
• Interpersonal psychotherapy- Some evidence
supporting role in pediatric depression
• ECT
• Light Therapy
• TMS (transcranial magnetic stimulation) – Preliminary
study
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Antidepressants—Mechanism
• SSRIs selectively block the reuptake of
5-HT (first-line pharmacotherapy)
• TCAs block the reuptake of 5-HT
and/or norepinephrine
• MAOIs block monoamine oxidase
(MAO), thereby blocking metabolism
and increasing neurotransmitter
availability in the synapse
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Response Rates in RCT’s of Antidepressants (for
depression) based on CGI (Clinical Global Impression)
MEDICATION
Drug
Placebo
P value
Fluoxetine (Prozac) (March ’04)*
56%
33%
0.02
Fluoxetine (Prozac) (Emslie ’97)
52%
37%
0.03
Fluoxetine (Prozac) (Emslie ’02)
61%
35%
0.001
Paroxetine (Paxil) (Keller ’01)**
66%
48%
0.02
Paroxetine (Paxil) (Unpublished)
69%
57%
NS
Paroxetine (Paxil) (Unpublished)
65%
46%
0.005
Citalopram (Celexa) (Wagner ’04)
47%
45%
NS
Sertraline (Zoloft) (Wagner ’03)
63%
53%
0.05
Escitalopram (Cipralex) (Emslie ’09)
64%
53%
0.03
*Fluoxetine alone compared to placebo
**Paroxetine compared to placebo
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Treatment Tactics—Depression
• Initiation
– Minimal or no response: total trial should not exceed
4-8 weeks
– Partial response: trial up to 12 weeks
– Monitoring: q1-2 weeks initially
– Initiate 2nd SSRI for non-response to first agent (x-taper)
• Continuation Phase
– Continue medications 6-9 months after symptom
remission
– When discontinuing, taper no more than 25% per week
– Monitor q 2-4 months as relapse most likely in first 8
months
• 60-70% recurrence of MDD in adulthood
• Maintenance: 3 years – lifetime (no data)
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Nuts and Bolts of SSRIs for
Depression
• How to choose an SSRI
–
–
–
–
–
Evidence
Drug-drug interactions
Side effect profile
Patient preference
Previous good result with family member
• Starting and titrating
– Start low, go slow (refer to SSRI table for starting dose)
– Increase to target dose* in 1-4 weeks
• Write prescription that makes increase to target dose
• See patient back after 1-4 weeks and increase dose
– Allow for trial of 6-8 weeks
• Discontinuation
*probable, effective dose
• Cross taper Copyright © The REACH Institute. All rights reserved.
Adverse events in
SSRIs and Non-SSRIs
•
Common
•
Less Common
•
Rare
• Nausea
• Rashes
• Increased bleeding
• Diarrhea
• Itchiness
• Increased bruising
• Headache
• Swelling
• Sexual side effects
• Feeling tired
• Sexual disturbance
• Vivid or strange dreams
• Nervousness
• Sleep difficulties
• Problems concentrating • Bruxism
• Blurry vision
• Increased risk of sunburn
• Increased yawning
• Hair loss
• Dry mouth
• Constipation
• Difficulty breathing
• Sweating
• Changes in patterns of
passing urine
• Serotonin syndrome
• Agitation
• Tremors
• Feeling dizzy
• Akathisia
• New onset suicidal ideation?
• Appetite changes
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The FDA Boxed Warning
“the Black Box”
• Applies to all medications with FDA indication for
depression - Antidepressants (SSRIs & non-SSRI’s)
• Suicidality
– Increased risk of suicidality in children, adolescents and
young adults w/ major depressive or other psychiatric
disorders especially during the first months of treatment
with antidepressants vs. placebo.
– Weigh risk vs. benefit: In short-term studies of
antidepressants vs. placebo, suicidality risk was not
increased in patients >24 y/o, and risk decreased in
patients >65 y/o.
– Observe all pts for clinical worsening, suicidality, or
unusual behavior changes
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Residual Symptoms & Relapse
• Patients with residual symptoms have
an increased risk of relapse
• Partial remission is related to poor
outcome in both medication and CBT
trials
• Increased risk for relapse (77% vs.
48%) by 36 months if SSRI is
discontinued – Emslie et al., 2008
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SSRIs for Depression in Adolescents
TRADE NAME GENERIC NAME
CELEXA
citalopram
LEXAPRO escitalopram
PROZAC
ZOLOFT
fluoxetine
sertraline
AVAILABLE
FORMS
DOSING
Tablets: 10, 20, 40
mg
Solution: 10
mg/5ml
Start with 10 mg in am
or pm
Dose range: 10-40 mg
daily
Start with 5 mg in am or
pm
PDR: Initial 10 mg qd, in
am or pm. Titrate: May
Tablets: 5, 10, 20 increase to 20 mg after
mg
3 weeks.
Solution: 5 mg/5ml Dose range 5-20 mg
Start with 10 mg/day.
After 1 week at 10
mg/day may increase to
Tablets: 10, 20, 40 20 mg/day
mg
Dose range: 10-60
Solution: 20
(doses above 20 often
mg/5ml
used for OCD)
TARGET DOSE
(ADOLESCENT)
FDA
COMMENTS
INDICATION
20
Adults: MDD
10
20
Tablets: 25, 50,
Start with 25 mg per day
50-100
100 mg
Dose range: 50-200 mg
Solution:
20 mg/ml
daily
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Good side effect
profile. Does
not usually
cause insomnia
Adults: MDD &
GAD (A)
S-isomer of
MDD (12-17)
citalopram
Adults: MDD,
OCD, Bulimia
Nervosa, Panic,
PMDD (A)
MDD (8-17
y/o), OCD (717 y/o)
Adults: MDD,
OCD, Panic,
PTSD, PMDD,
SAD (A)
OCD (6-17 y/o)
Weekly form
available. Long
half life prevents
withdrawal
symptoms If
dose is missed
GLAD-PC Guidelines:
Ongoing Management
• Perform systematic and regular tracking of goals
and outcomes from treatment, including
assessment of depressive symptoms and
functioning in several key domains: home,
school, and peer settings.
• Reassess diagnosis and initial treatment if no
improvement is noted after 6-8 weeks of
treatment. Mental health consultation should be
considered.
• Ask suicidality questions and monitor warning
signs.
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Peer Practice: Suicide Risk
and Safety Planning
• Task One: Read the Unit F workbook pages on
suicide risk assessment and preventing suicide
(F 1.1 –1.4).
• Task Two: Discuss the boxed warning and safety
planning with parent (F1.1-1.3).
– In pairs and using the Boxed Warning and Ways to
Prevent Suicide handouts, discuss with the parent
how to safety-proof the home and monitor suicide
risk.
• Task Three: Volunteer to role play Task 2 with a
parent in front of the entire group
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Treatment Summary
• Involve and educate parents & youth about MDD.
See www.parentsmedguide.org for parent handouts
• Mild depression needs “active monitoring” &
support
• Moderate to severe depression may need
combined treatment (SSRI plus EBP)
• Any child on medication needs to be monitored
closely.
• Medication can be an important component of
treatment, but medication alone is rarely the
answer. Your active support & monitoring, +/- an
EBP (CBT or IPT) always essential.
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Ask the Experts:
Treatment of Child and
Adolescent Depression
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REMINDER:
Please fill out Unit H
evaluation
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RESOURCE SLIDE
Why CBT? Acute CBT Trials in Youth w/MDD
Effect Size
High
Moderate
Modest
1.4
1.2
Effect Size
1
0.8
0.6
0.4
0.2
0
-0.2
Trial, Year
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Effect size: .34;
Weisz et al., 2006
RESOURCE SLIDE
Meta-Analysis of SSRI RCTs
• 27 major depressive disorder (MDD) trials
• Pooled risk differences (benefit vs. risk) favored
antidepressants vs. PBO for MDD
– Effect size=0.25
• Efficacy moderated by: Age, Duration of MDD,
and # of sites in the RCT
• Children < 12 y.o.: only fluoxetine showed
benefit over PBO
Bridge JA , et al. JAMA 2007;297:1683-1696
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RESOURCE SLIDE
TADS CDRS Findings:
(Children’s Depression Rating Scale)
Mean CDRS Score - Adjusted
60
COMB
50
FLX
CBT
PBO
40
30
Baseline
Week 6
Week 12
Stage I Assessments
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TAD S
RESOURCE SLIDE
Discontinuation symptoms
• Flulike symptoms (e.g., headache, diarrhea, nausea,
vomiting, chills, dizziness, fatigue) may occur when
suddenly stopping SSRI medications, and this is more
common in agents with short half-lives.
• SSRIs also have a higher margin of safety in overdoses
compared to TCAs and MAOIs.
• Deaths have been reported with large ingestions of SSRIs
(either alone or in combination with other medications).
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RESOURCE SLIDE
Emslie Fluox
• Emslie et al. Am J
Psychiatry Feb 2008
• 102 Adolescents
Survival Curve Time to Relapse
– Mean age 11.8+2.8 yr.
– MDD Responders
• Fluoxetine X 12 Weeks
• CGI-S of 1 or 2 & CDRSR < 28
– Randomized
• Fluoxetine
• Placebo
– Relapse
• Score > 40 CDRS X 2
Weeks
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RESOURCE SLIDE
Continuation Treatment
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Resource Slide: GLAD-PC Toolkit
• Psychoeducation Materials/Provider
– What to tell parents about depression?
• Psychoeducation Materials for Children/Adolescents
– Self-Care Success
• Psychoeducation Materials for Parents
– Depression Fact Sheet
– FAQs about Antidepressants
– Family Support Action Plan (NAMI, DBSA) (long version)
• Other Patient and Family Handouts
– Facts on Psychological Counseling
– Communication Tools Between Providers
• Suicide
– Suicide & SSRIs
– Suicide prevention tips
www.glad-pc.org
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