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Depression Continuity Clinic Objectives Continuity Clinic Background • Prevalence rates for depression: – 1% to 2% of prepubertal children – 3% to 8% of adolescents. • Depression and bipolar disorder equally common in both sexes. • Unipolar depressive disorders in teens more common in girls than in boys (ratio of 3:1) • Early onset of puberty in girls increases the risk for depression. Continuity Clinic Clinical Features & When to Consider Diagnosis • Sad, irritable, or angry – may present with school or behavioral problems • Somatic complaints – headache, stomachache, muscle weakness, decreased or increased appetite, fatigue, insomnia, hypersomnia, or disturbed sleepwake cycles • Self-injurious behaviors or suicidal ideation, plan, and intent Continuity Clinic Identifying Risk Factors Environmental • • • • Abuse or neglect Parental substance abuse Marital problems Low socioeconomic status and education level • Loss of parent, sibling, or close friend • Stress related to adolescent developmental or issues of sexuality (eg, homosexuality) Continuity Clinic Identifying Risk Factors Genetic • Depressed parent contributes both genetic vulnerability & emotional unavailability that can contribute – combination of adverse life events and the presence of the shorter allelic form of the serotonin transporter gene results in earlyonset depression • Smaller prefrontal cortex and basal ganglia in depressed individuals Continuity Clinic Identifying Risk Factors • Medications – glucocorticoids, immunosuppressives, isotretinoin, antiviral agents • Chronic illness – such as cystic fibrosis, juvenile diabetes Continuity Clinic Diagnosis The Basic Steps • Are symptoms present? • Evaluate child’s current level of functioning relative to his or her baseline • Any potential for self-injurious behavior, suicidal ideation, or suicide attempt? • History taken from: – Patient – Parents – Others : teachers, counselors, or coaches. Continuity Clinic Diagnosis Tools • Children’s Depression Inventory (CDI) – assesses the severity of depression in prepubertal school-age children • Mood and Feelings Questionnaire (MFQ) Continuity Clinic Adolescents • Beck Depression Inventory (BDI) Reynolds Adolescent Depression Scale (RADS-2) Diagnosis Tools • The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Toolkit – Has child and parent report measures and scoring instructions on their web site http://www.thereachinstitute.org/files/documents/GLAD-PCToolkit.pdf – This user-friendly online resource also includes management flowcharts, scales, and educational materials in English and Spanish as well as tracking forms and information on billing Continuity Clinic Treatment Pharmacological • Currently, fluoxetine (Prozac)is the only antidepressant approved by the FDA in children and adolescents – research studies have demonstrated efficacy of other drugs such as citalopram, paroxetine, and sertraline • Dosing of Fluoxetine – Starting at 2.5 mg/day for prepubertal children – 10 mg/day for older adolescents – Most patients respond to fluoxetine at doses ranging from 20 to 80 mg/day Continuity Clinic Treatment Pharmacological • 2006 FDA meta-analysis of children and adolescents taking SSRIs for depression – found an increased risk of suicidality in those patients treated with drugs versus those given placebo. • Subsequent meta-analysis including additional studies revealed that those who benefited from SSRI treatment outnumbered those who became suicidal during SSRI treatment by a ratio of 14:1. Continuity Clinic Continuity Clinic