Download GLAD PC

Management of Adolescent Depression
Amy Cheung, MD
Youth Division
Department of Psychiatry
Sunnybrook Health Sciences Centre
Outline
• Background
• Guidelines for Adolescent Depression in Primary
Care (GLAD PC)
– Development Process
– Recommendations
• Implementation plans
Major Depressive Disorder in Adolescents
• Common in adolescence – 8% lifetime prevalence
• Significant burden of illness on patients and families
• High rates of MDD in primary care settings - up to 28%
• 50% of youth with MDD missed in primary care settings
• Most clinicians think it is their responsibility to identify depression
Cheung et al., 2006;Bartlett et a., 1991;Chang et al., 1988;
Kramer & Garralda, 1998;Olson et al., 2001;Jensen, 2002
Major Depressive Disorder in Adolescents
• Most clinicians “intend” to screen for depression and suicide, but do it
less often than other areas (sexual activity/birth control), only 15%
and 17% do it always
• Shortage of mental health professionals in both US and Canada
• Barriers to accessing services – only 50% utilize services
• Critical to improve collaborative care in Canada
Halpern-Felsher et al, 2000; Middleman et al., 1995;
Kates et al., 1996;Cheung et al., 2007
GLAD-PC Steering Committee & Liaisons
Steering Committee
Boris Birmaher, MD
Greg Clarke, PhD
Allen Dietrich, MD
Bernard Ewigman, MD
Sherry Glied, PhD,
Charles Homer, MD
Miriam Kaufman, MD
Stanley Kutcher, MD
James Perrin, MD
Brenda Reiss-Brennan, RN
Ruth E. K. Stein, MD
Angela Diaz, MD
John Campo, MD
Dave Davis, MD
Graham Emslie, MD
Eric Fombonne, MD
Kimberly Hoagwood, PhD
Danielle Laraque, MD
Kelly J. Kelleher, MD
Michael Malus, MD
Harold Pincus, MD
Diane Sacks, MD
Bruce Waslick, MD
Organizational Liaisons
Darcy Gruttadaro (NAMI)
Sue Bergeson (DBSA)
Mike Faenza (NMHA)
Eric Fombonne (CPA, CACAP)
Ben Vitiello (NIMH)
James MacIntyre (AACAP)
Bruce Waslick (AMA)
Deborah Ebner (SAM)
Diane Sacks (CPS, AAP)
Michael Malus (CCFP)
Angela Diaz (AAP)
Judy Garber (APA)
Jim Perrin (AAP)
Kelly Kelleher (AAP)
David Fassler (APA)
Bernard Ewigman (AAFP)
Stanford Friedman (SDBP)
Sandra Spencer (FFCMH)
Vicky Wolfe (CPA)
GLAD-PC Support
Project Team
Peter S. Jensen, MD
Rachel Zuckerbrot, MD
Anthony Levitt, MD
Funders
CSAT, SAMHSA
NY Office of Mental Health
University of Toronto
NY Council C&A Psychiatry
Kellogg Foundation
Amy Cheung, MD,
Kareem Ghalib, MD
Josiah Macy, Jr. Foundation
Lowenstein Foundation
AAP NY Chapters 1,2&3, District II
NY Academy of Medicine
Civic Research Institute, Inc.
GLAD-PC Development Process
• Initial partnership between the Center for the
Advancement of Children’s Mental Health,
Columbia University and University of Toronto
• 16 focus groups: primary care providers,
adolescents, parents (n>100)
• Systematic Evidence-Based Literature Reviews
• Consensus Survey and Conference
GLAD PC
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Surveillance and Identification
Assessment and Diagnosis
Initial Management
Treatment
Ongoing Management
GLAD-PC Guidelines:
Identification/Surveillance
Recommendation I: Patients with depression risk
factors (such as history of previous episodes, family
history, other psychiatric disorders, substance abuse,
trauma, psychosocial adversity, etc.) should be
identified and systematically monitored over time for
the development of a depressive disorder.
GLAD-PC Guidelines:
Identification/Surveillance
• Targeted screening versus universal screening
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Previous history of depression
Family history of mood disorder or other mental illness
Trauma/ongoing conflict
Medical illnesses
• Strategies
– General questions “How is your mood?” “Have there been
changes in your interests?”
– Screening tool (handout)
GLAD-PC Guidelines:
Assessment/Diagnosis
Recommendation I: PC clinicians should evaluate for
depression in high-risk adolescents as well as those who
present with emotional problems as the chief complaint.
Clinicians should assess for depressive symptoms based
on diagnostic criteria established in the DSM IV or ICD
10 and should use standardized depression tools to aid in
the assessment.
Signs and Symptoms of Depression
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Sadness
Irritability
Low energy/Fatigue
Poor concentration
Low motivation/interest
Sleep disturbance
Change in appetite
Thoughts of death
GLAD-PC Guidelines:
Assessment/Diagnosis (cont.)
Recommendation II: Assessment for depression
should include direct interviews with the patients and
families/caregivers and should include the
assessment of functional impairment in different
domains and other existing psychiatric conditions.
Overlap Between Manic and Depressive
Symptoms
Mania
• Euphoria
• Decreased need for
sleep
• Increased energy
• Racing thoughts
• Increased self-esteem
(grandiosity)
Depression
• Irritability
• Insomnia
• Agitation
• Impaired concentration
• Delusions
• Hallucinations
• Lack of interest
• Too much sleep
• Fatigue
• Decreased self-esteem
• Suicidal thoughts
Overlap Between Manic and ADHD
Symptoms
Mania
• Elation
• Decreased need for
sleep
• Racing thoughts
• Increased self-esteem
(grandiosity)
• Delusions
• Hallucinations
• Hypersexuality
ADHD
• Irritability
• Agitation
• Impaired concentration
• Increased energy
• Impulsivity
• Hyperactivity
• Increased
speech
• Persistent symptoms
• Onset before age 7
GLAD-PC Guidelines:
Initial Management
Recommendation I: PC clinicians should educate and
counsel families and patients about depression and
options for the management of the disorder. Clinicians
should also discuss limits of confidentiality with the
adolescent and family.
GLAD-PC Guidelines:
Initial Management
• Follow-up
– Reminders
• Psychoeducation
– What is depression?
– What are the treatment options?
– The role of sleep/nutrition/stress/social activities
GLAD-PC Guidelines:
Initial Management (cont.)
Recommendation II: PC clinicians should develop a
treatment plan with patients and families and set specific
treatment goals in key areas of functioning including
home, peer, and school settings.
GLAD-PC Guidelines:
Initial Management (cont.)
Recommendation III: The PC clinician should establish
relevant links/collaboration with mental health resources in
the community, which may include patients and families who
have dealt with adolescent depression and are willing to serve
as resources to other affected adolescents and their family
members.
GLAD-PC Guidelines:
Initial Management (cont.)
Recommendation IV: All management must include the
establishment of a safety plan, an emergency communication
mechanism should the patient deteriorate, become actively
suicidal or dangerous to others, or experience an acute crisis
associated with psychosocial stressors especially during
period of initial treatment when safety concerns are highest.
GLAD-PC Guidelines:
Treatment
Recommendation I: After initial diagnosis, in cases
of mild depression, clinicians should consider a
period of active support and monitoring before
starting other evidence-based treatment.
GLAD-PC Guidelines:
Treatment (cont.)
Recommendation II: If a PC clinician identifies an
adolescent with moderate or severe depression or
complicating factors/conditions such as co-existing
substance abuse or psychosis, consultation with a mental
health specialist is recommended. Appropriate roles and
responsibilities for ongoing management by the PC and
mental health clinicians should be negotiated. The
patient and family should be consulted and approve the
roles of the PC and mental health professionals.
GLAD-PC Guidelines:
Treatment (cont.)
Recommendation III: PC clinicians should recommend
scientifically-tested and proven treatments (i.e.,
psychotherapies such as cognitive behavioral therapy or
interpersonal therapy, and/or antidepressant treatment
such as SSRI’s) whenever possible and appropriate to
achieve the goals of the treatment plan.
GLAD-PC Guidelines:
Treatment
• 2 types of evidenced-based psychotherapy
– Cognitive Behavioural Therapy (CBT)
– Interpersonal Therapy
• CBT easier to incorporate into clinical practice
– Spend time with friends/socially
– Rational thinking
– Relaxation strategies
GLAD-PC Guidelines:
Treatment
• Medication efficacy and safety
– FDA and Health Canada Warnings
– First-line SSRI’s
• Fluoxetine 10 mg to 40 mg
• Escitalopram 10 mg to 20 mg
• Sertraline, Fluvoxamine, Citalopram
– Some suggestion of differences among SSRI’s
– No monitoring schedule outlined by FDA or Health Canada
• Weekly contact for first few weeks
• Reviews of side effects (Handout)
GLAD-PC Guidelines:
Treatment (cont.)
Recommendation IV: PC clinicians should monitor
for the emergence of adverse events during
antidepressant treatment (SSRIs).
Management of Major Depressive Disorder in
Adolescents
• Lack of psychotherapy resources in the community
• Prescribing decreased since the 2004 FDA and Health Canada warning
• Likely due to both clinician judgment and patient/family preference
• Parallel increase in suicides in youth in both US and Manitoba
• Only 3% following FDA recommendations and only a small minority
seeing patients monthly for first 3 months of initiating medication
• Need for greater integration of warnings into clinical practice
Linberry et al., 2006; Cheung et al., 2008; Katz et al., 2008;
GLAD-PC Guidelines:
Ongoing Management
Recommendation I: Systematic and regular tracking
of goals and outcomes from treatment should be
performed including assessment of depressive
symptoms and functioning in several key domains:
home, school, and peer settings.
GLAD-PC Guidelines:
Ongoing Management (cont.)
Recommendation II: Diagnosis and initial treatment
should be reassessed if no improvement is noted after
6-8 weeks of treatment. Mental health consultation
should be considered.
Reassessment of Diagnosis
• Low energy/Fatigue
– Nutrition/Exercise, Worries/Anxiety, Anemia
• Poor concentration
– Attention Deficit Disorder, Stresses/Trauma,
Worries/Anxiety
GLAD-PC Guidelines:
Ongoing Management (cont.)
Recommendation III: For patients achieving only
partial improvement after PC diagnostic and therapeutic
approaches have been exhausted (including exploration
of poor adherence, co-morbid disorders, and ongoing
conflicts or abuse), a mental health consultation should
be considered.
GLAD-PC Guidelines:
Ongoing Management (cont.)
Recommendation IV: PC clinicians should actively support
depressed adolescents referred to mental health to ensure
adequate management. PC clinicians may also consider
sharing care with mental health services where possible.
Appropriate roles and responsibilities, and co-ordination of
care, should be negotiated between the PC clinician and the
mental health specialist.
GLAD-PC Toolkit
(downloadable from www.gladpc.org)
• Screening/assessment instruments
• Algorithm/Flow Sheet
• Screen for parental depression (i.e., PHQ-9, 2question screen)
• Treatment Choices-Active Support guide,
Psychotherapy guide and Medication guide and
dosage charts
• Fact sheet/family education materials
• Self-management tools
GLAD-PC Guidelines:
Implementation Plans
Toolkit development
• Pilot testing with family medicine and pediatrics
• Modification based on feedback
• Slight variations based on different clinician groups, and
practice models
GLAD-PC Guidelines:
Implementation Plans
Testing of collaborative care models
• Shared care
• On-site mental health support
• Telephone consultation
GLAD-PC Guidelines:
Implementation Plans
Testing of collaborative care models
• Involvement of funding agencies
• Development of alternative funding plans
• Initial studies to examine feasibility and qualitative data on
models
• Larger randomized controlled trial to examine changes in
patient outcomes
Questions/Contact
• www.gladpc.org
• [email protected]
• Other Resources
– Mood Disorders Association of Ontario
– Ementalhealth.ca