1、Recognizing and Managing Depression in Primary CareCharles E.Irwin,Jr.,MDDivision of Adolescent MedicineDepartment of PediatricsUniversity of California,San FranciscoFebruary 2014USPSTF Recommendation Screening of adolescents(12-18 yrs)for major depressive disorder(MDD)when systems are in place to e
2、nsure accurate diagnosis,psychotherapy(CBT or interpersonal)and follow up.March 2009 http:/www.ahrq.gov/clinic/uspstf09/depression/chdeprrs.htm Outline General Overview How to Make the Diagnosis Hx taking Physical exam Screening Instruments Epidemiology ManagementMajor Depressive Disorder Primary ca
3、re clinicians say of the teens they see:-9-21%have MDD Impact school performance Substance use/abuse Associated with increased risk of suicidal behaviorPossible Symptoms of MDD Appetite disturbance Sleep disturbance Fatigue or loss of energy Cardiopulmonary symptoms GI symptoms Neuromuscular symptom
4、s Gynecological symptoms Dermatological symptoms Behavioral symptomsHistory and Physical Exam Patient historyHEADSSS Family history(may need to ask parents separately)Complete physical exam BMI Neuro exam Consider labsHomeEducation/EmploymentEatingActivitiesDrugsSexSuicide/Safety StrengthsSIGECAPSlo
5、oks for criteria for Major Depressive DisorderS-Sleep disturbance:insomnia or hypersomniaI-Interest or pleasure:diminished in almost all activitiesG-Guilt:feelings of excessive worthlessness or guiltE-Energy:fatigue or energy loss nearly every dayC-Concentration:diminished.A-Appetite:weight loss or
6、decreased appetite P-Psychomotor agitation or retardationS-Suicide:recurrent thoughts of death or suicidal ideationScreening Instruments PHQ-A Patient Health Questionnaire for Adolescents BDI PC Beck Depression Inventory Primary CareSymptoms and Criteria for a Major Depressive EpisodeDepressed mood
7、or loss of interest or pleasure for a 2-week period(or irritability among children and adolescents),plus:Four or more of the following symptoms in the same 2-week period:Significant weight loss(when not dieting)or weight gain Insomnia or hypersomnia nearly every day Being restless or being slow(psyc
8、homotor agitation or retardation)Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt Inability to concentrate Recurrent thoughts of death or suicide ideations or plansDSM VSymptoms in Adolescents DSM-IV sx of MDDAs seen in teens Depressed mood mos
9、t of the dayIrritable or cranky moodLoss of interest in once favorite activitiesLoss of interest in sports,video games,activities with friendsWeight loss/gainSomatic complaints,failure to gain wtInsomnia/hypersomniaExcess late night TV,refusal to wake for schoolPsychomotor agitation/retardationTalk
10、of running away from homeFatigue,loss of energyPersistent boredomDecreased concentration,indecisivePoor school performance,frequent absencesLoss of self esteem,guiltOppositional/negative behaviorDepressive Symptoms in Teens More sleep and appetite disturbances,delusions,suicidal ideation and attempt
11、s,and impairment of functioning than younger children with MDD More behavioral problems and fewer neurovegetative symptoms than adults with MDD Differential Diagnosis of Depression Anemia Mononucleosis Hypothyroidism Hyperthyroidism Inflammatory bowel disease Collagen vascular diseaseMajor Depressio
12、n&Co-morbidity 76%with major depression also had other diagnoses,two thirds of which preceded the depression diagnosis.Previous diagnoses among the 76%include:Anxiety disorders(40%)Conduct disorders(25%)Addictive disorders(12%)Source:Kessler,1998Symptoms of Bipolar disorder in Adolescence:Markedly l
13、abile mood Agitated behavior Pressured speech Racing thoughts Sleep disturbances Reckless behaviors Illicit activities Spending sprees Psychotic symptoms such as hallucinations,delusions,irrational thoughtsRisk factors for Depression Genetics 20%have+family hx;female gender Biology puberty,premenstr
14、ual,postpartum Environment Family conflict,substance use at home Negative life events Divorce,loss of parent Individual factors Poor self esteem,poor school performance Co morbidities Mental health Chronic medical conditionsEpidemiology of Depression Prevalence of MDD in children(13 y.o.)is 2.8%,wit
15、h 1:1 ratio of girls to boys In adolescence(13-18 y.o.),prevalence is 5.6%,with a higher prevalence for girls than boys(5.9%vs.4.6%)Lifetime prevalence among adolescents is 20%.SOURCE?Depression:Broad MeasureSource:Grunbaum et al.,2008;YRBS;Self-reportSadness or Hopelessness which Prevented Usual Ac
16、tivities by Gender and Race/Ethnicity,High School Students,200734.6%17.8%34.5%24.0%42.3%30.4%35.8%21.2%Depression:Broad MeasureSource:Grunbaum et al.,2008;YRBS;Self-reportSadness or Hopelessness which Prevented Usual Activities by Gender and Race/Ethnicity,High School Students,2011Suicide:Seriously
17、ConsideredGender and Race/Ethnicity,High School Students,200817.8%10.2%18.0%8.5%21.1%10.7%18.7%10.3%Source:Grunbaum et al.,2008;YRBS;Self-reportEpidemiology of Depression At any given time,up to one in 13 adolescents have major depression making it more common than asthma Each successive generation
18、since 1940 is at greater risk of developing depression,and is identified at a younger agePrognosis 70%of youth with a major depressive episode will have another episode in next 5 years Youth with depression have a 4x increased risk of an adult depressive disorder 20-40%of children with major depress
19、ion will develop bipolar disorder eventually Can lead to impaired functioning in relationships,school etcPrinciples of Treatment Ensure safety Develop an alliance with the teen and parents Confidentiality?Psycho-education Addresses signs and symptoms of depression Stresses importance of psychotherap
20、y and psychiatric medications Addresses misconceptionsIndications for PCP Care vs.Specialist in Adolescents with DepressionIndications for PCP Initial episode of depression Absence of coexisting conditions Ability to make a no suicide contractIndications for Specialist Chronic,recurrent depression L
21、ack of response to initial treatment Coexisting substance abuse Recent suicide attempt or current suicidal ideation Psychosis Bipolar High level of family discord Inability of family to monitor patients safety Depression-Treatment Options Cognitive Behavioral Therapy(CBT Interpersonal therapy Pharma
22、cotherapy First line therapy,SSRIs Others SNRIs,Buproprion,TCAs,Combinations of the above methods works best Family therapyABCs of CBTYou cannot control how you feel,but you can control what you think about,and this can influence how you feelCognitive Behavioral Therapy Treatment targets patients th
23、oughts and behaviors to improve mood Essential elements of CBT include:increasing pleasurable activities reducing negative thoughts and improving assertiveness and problem-solving skills to reduce feelings of helplessness.Interpersonal Therapy for Depression Interpersonal problems may cause or exace
24、rbate depression and that depression,in turn,may exacerbate interpersonal problems.Treatment will target patients interpersonal problems to improve both interpersonal functioning and his/her mood.Pharmacological Treatment Selective Serotonin Reuptake Inhibitors(SSRIs)are first line for medication fo
25、r adolescents for depression and anxiety Fluoxetine,only drug approved for treatment of MDD among youth.What is a“Black Box Warning?”It is a required statement on the package insert that accompanies every prescription It is the strongest warning from the FDA to prescribers and patients regarding pos
26、sible adverse effects of a medication HOWEVER,it is not a contraindication for use of a medicationBlack Box Warning FDA put on all antidepressants in 2004.“.increase the risk of suicidal thinking and behavior(suicidality)in children and adolescents with major depressive disorder(MDD)or other psychia
27、tric disorders.”Rx with SSRIs leads to 1-2%absolute increase in risk of suicidalityIf starting an antidepressant Confirm your diagnosis BDI,PHQ-A Start low and advance slowly Follow up frequently-the black box warning recommends weekly for the first 4 weeks and when a dosage change is made If no imp
28、rovement after 6 weeks consider changing meds and reconfirm diagnosis If the patient has a family member who has had a good response to a particular SSRI,that may be helpful in selecting a medication.Talking Points to Patients and Families about SSRIs Need to supervise medication administration;If y
29、our child has threatened or attempted suicide,keep medication in a secure location.Likely duration of medication treatment 6 months to 1 year after symptoms improve and sometimes longer Medication should be stopped gradually under doctors supervision,due to the possibility of withdrawal symptomsSSRI
30、s Side Effects Nausea Loss of appetite GI upset Minimal weight loss Headache Agitation Akasthesia Sexual dysfunction Increased clotting time Hypomania or mania Sedation or insomnia Vivid dreamsQuestions at Follow Up Missed doses Stomachaches/Headaches Restlessness Unsettled thoughts Suicidal thought
31、s Positive effectsInitial Strategies Know the resources in your community Education for patients and families No suicide contracts Removing firearms,medications,sharp objects from where they are accessible.Major burden disabling condition Hx taking/Screening tests are effective in making dx of MDD E
32、ffective treatment leads to decrease in symptoms&improved functioning Harm from treatment minimal Centers for Disease Control and Prevention(CDC),Youth Risk Behavioral Surveillance System,U.S.2007,MMWR,June 6,2008/Volume 7/Number SS-4,http:/www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf,Accessed
33、 05/01/09.Goldenring JM,Rosen DS.Getting into adolescent heads:An essential update.Contemporary Pediatrics 2004;21:64-90Graber JA,Sontag LM.Internalizing Problems during Adolescence.In:Lerner RM,Steinberg L,eds.Handbook of Adolescent Psychology,3rd edition.Hoboken,NJ:Wiley,2009Hagan JF,Shaw JS and D
34、uncan PM(eds.).Bright Futures,3rd Edition.Vol.Hagan JF,Shaw JS,Duncan PM(eds)Bright Futures,3rd Edition,Elk Grove Village,IL:American Academy of Pediatrics,2008.Elk Grove Village,IL:American Academy of Pediatrics,2008Kessler RC,Walters EE.Epidemiology of DSM-III-R major depression and minor depressi
35、on among adolescents and young adults in the National Comorbidity Survey.Depress Anxiety 1998;7:3-14Lock J,Walker LR,Rickert VI and Katzman DK.Suicidality in adolescents being treated with antidepressant medications and the black box label:position paper of the Society for Adolescent Medicine.J Adol
36、esc Health 2005;36:92-3March J,Silva S,Petrycki S,et al.Fluoxetine,cognitive-behavioral therapy,and their combination for adolescents with depression:Treatment for Adolescents With Depression Study(TADS)randomized controlled trial.JAMA 2004;292:807-20March JS,Silva S,Petrycki S,et al.The Treatment f
37、or Adolescents With Depression Study(TADS):long-term effectiveness and safety outcomes.Arch Gen Psychiatry 2007;64:1132-43Melvin GA,Tonge BJ,King NJ,Heyne D,Gordon MS and Klimkeit E.A comparison of cognitive-behavioral therapy,sertraline,and their combination for adolescent depression.J Am Acad Chil
38、d Adolesc Psychiatry 2006;45:1151-61Sharp LK,Lipsky MS.Screening for depression across the lifespan:a review of measures for use in primary care settings.Am Fam Physician 2002;66:1001-8Stein RE,Zitner LE and Jensen PS.Interventions for adolescent depression in primary care.Pediatrics 2006;118:669-82
39、U.S Preventive Services Task Force(USPSTF).Screening and Treatment for Major Depressive Disorder(MDD)in Children and Adolescents.U.S Department of Health And Human Services,Agency for Health Care Research and Quality,March 2009,http:/www.ahrq.gov/clinic/uspstf09/depression/chdeprrs.htm,Accessed 05/0
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