1 Adolescent Depression Danielle Bradshaw, DO Diplomate of the American Board of Psychiatry and Neurology Adult and Child/Adolescent Psychiatry
2 Adolescence When does it start? When does it end? Characteristics: Puberty Social Role in family Role in society Experimentation
3 Risk factors for Adolescent Depression Anxiety, eating disorders, ADHD Family history Family dysfunction Stressful life event Victim or witness of abuse, domestic violence Chronic medical issues: Diabetes Female Minimal social support, friends or family Self esteem/self image issues: Bullying Obesity Handicap, learning disabilities, speech disorders Gay, lesbian, transgendered
4 Prevalence 2% children 4-8% adolescents Male: Female 1:1 in children 1:3 in Adolescents
5 Depression- must have 5 Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feeling sad or empty) or observation made by others (e.g., appears tearful). (In children and adolescents, this may be characterized as an irritable mood.) Markedly diminished interest or pleasure in all, or almost all, activities every day Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation nearly every day Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt nearly every day Diminished ability to think or concentrate, or indecisiveness, nearly every day Recurrent thoughts of death
6 Depression Must last for 2 weeks Must cause impairment in social, academic or occupational functioning Must represent a distinct change in functioning Must NOT be caused by substances, a medical condition, or be better accounted for by another medical condition
7 Differential Diagnosis Medical causes: Hypothyroidism Mono Anemia Autoimmune disorders Cancer Pregnancy
8 Adjustment Disorder Negative event-death, divorce, move Symptoms start within 3 months Distress or functional impairment Does not meet full criteria for MDD Refer for individual therapy
9 Persistent depressive disorder/ Dsythymia 2 MDD symptoms Depressed or irritable daily for 1 year Refer for therapy Consider antidepressants
10 Grief Sadness, in waves-sad at times then Ok. Not suicidal, still functioning Key differentiating factor- disturbance in sense of self worth Refer for therapy Watch to see if improves or MDD develops
11 Substance use disorders Withdrawal from meth, stimulants, cocaine, cannabis, alcohol Excessive sleep Changes in appetite Avoiding family Change in friends, style, behavior Consider drug testing along with routine labs Refer for treatment
12 Prodromal schizophrenia or other psychotic disorder Isolative Give up social and recreational activities Stare into space, out window, a volition Flat affect Mental clouding, decline in academic performance Paranoid ideation, unusual obsessions, illogical thoughts ***Prompt referral to psychiatry
13 Bipolar disorder Bipolar I manic episodes last 1 week Bipolar 2 manic episodes last 4 days What is mania? a distinct change in behavior and functioning from baseline, not caused by substances or medical condition. Need 3 symptoms if mood is elevated Need 4 symptoms if mood is irritable
14 Mania- must be a marked change from baseline Inflated self-esteem or grandiosity Decreased need for sleep (e.g., one feels rested after only 3 hours of sleep) More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Decreased ability to focus Increase in goal-directed activity (projects) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences- money, sex,masturbation
15 What mania is NOT Mood swings- fine one minute then angry for no reason Mood reactivity, over sensitivity Stable trait irritability think anxiety Tendency to get angry easily Yells, argues
16 Epidemic of bipolar misdiagnoses Dangerous meds for a lifetime Forming an identity around diagnosis Not receiving proper treatment for actual diagnosis Refer to psychiatrist/ psychologist for diagnosis, therapy, case management
17 Incipient Personality Disorders Cutting, self harm Recurrent suicidal gestures, statements Chronic feeling of emptiness Mood swings Intense anger outbursts Unstable and intense relationships Unstable self image Issues with abandonment Often history of abuse and neglect ***Refer to psychiatrist/case management/therapist
18 Parent-child Relational Problems Negative or dysfunctional pattern of interaction between parent and child, eg. Overprotection, over control, mom needs to get a life Isolates at home, avoids activities Frequent arguments How is the child at school? With friends? Refer for Family therapy
19 You have an adolescent with depression. Now what?
20 Suicide Assessment is critical!!!!!!!!!!!!!!!!!!! Are you having thoughts that life isn't worth living? Do you ever wish you were dead? Do you think about killing yourself? Are you planning to kill yourself? How would you kill yourself? Is there anything holding you back from killing yourself? Is there something that might happen that would trigger you to kill yourself? DOCUMENT at each visit!!!!!!!!!!!!!
21 Risk Assessment #1 History of past suicide attempt Family history of suicide attempt Depression, mania or psychosis Access to firearms or lethal weapons Use of drugs and alcohol Stressful life event, loss of loved one Incarceration Childhood sexual or physical abuse Low levels of parental supervision /involvement History of self harm behavior-cutting or burning self
22 Ask about abuse!!!!!!!! And report it! Is someone hurting you or mistreating you? Do you know what sexual abuse means? Is someone sexually abusing you? Bullying Relationship violence Trafficking
23 Other work up Labs to rule out medical causes Drug testing Pregnancy test
24 Treatment Report abuse or bullying Safety plan: (written contract with parents) Keep all weapons locked Keep all medications- especially Tylenol locked Patents are to dispense ALL medications to kids one pill at a time Crisis line for county dmh.mo.gov/crisis SUICIDE If high risk refer for case management ASAP If parents are not willing to take necessary precautions= Medical neglect
25 Treatment- address causal factors first Address medical, educational, social factors Eg. obese, getting bullied, missing school, failing Grief / Loss/ Past abuse: Individual therapy, trauma focused CBT Family Dysfunction: Family therapy Case management Parent transplant Address substance abuse: Drug and alcohol treatment Consider drug testing
26 Treatment AACAP practice parameter: For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial of specific types of psychotherapy and /or antidepressants is indicated.
27 Treatment To consolidate the response to acute treatment and avoid relapses, treatment should always be continued for 6-12 months. For some treatment should be maintained longer
28 Meds- FDA approved Prozac/fluoxetine: ages 8-17 Start 10 mg Can increase by 10 mg after 2 weeks Lexapro/escitalopram: ages Start 10 mg Can increase to 20mg after 3 weeks
29 Not FDA approved for MDD Zoloft/sertraline: FDA approved for OCD for ages 6-17 Age 6-12 : start 25mg Age : start 50mg Increase cautiously after 2-3 weeks
30 Side effects Nausea Diarrhea Headache Tremor Serotonin syndrome- diaphoresis, tachycardia,clonus, delirium, mydriasis
31 FDA black box warning Increase in suicidal thoughts(not events) from 2% in control group to 4% with group on antidepressants Increased risk up to age 24
32 Activation Syndrome Activation syndrome: worse with paxil/paroxetine, Effexor/venlafaxine Increased activity, agitation Increased anxiety and irritability Decreased sleep Possible psychosis This syndrome is a known side effect- it does NOT mean individual has bipolar Ok to try a different antidepressant
33 Treatment algorithm (Texas Children's) Start with Lexapro, Prozac, Zoloft or therapy alone If no response after 4 weeks switch to one of above meds mot yet tried If partial but incomplete response after 4 weeks, consider augmentation with remeron/mirtazapine, low dose ( mg) lithium, low dose wellbutrin/bupropion Monotherapy with alternative class: wellbutrin, Effexor, Cymbalta, mirtazapine, trazodone
34 Therapy First line treatment for mild to moderate depression, adjustment disorder, grief, dysthymia, anxiety, ptsd, personality disorders Meds + therapy more effective than meds alone Kids who get meds +therapy less likely to have recurrence Have a list of good therapists to refer to Supportive therapy versus CBT Explain need to invest 8 or more weeks to see results
35 Handout for patient/parent Safety plan: signed contract with parents) Keep all weapons locked Keep all medications- especially Tylenol locked Patents are to dispense ALL medications to kids one pill at a time Crisis line for county dmh.mo.gov/crisis 911 if child is at imminent risk SUICIDE Local agencies, individual and family therapists, substance treatment resources. Highlight most applicable
36 Return visits Ideal is weekly for 1 st month or until stabilized 2-3 weeks ok if low risk
37 When to refer to a psychiatrist Anytime you want to High risk for suicide Self injury, high risk behavior Not responding to treatment Multiple comorbidities Mania, suspected bipolar Psychosis, bizarre behavior Significant family dysfunction
38 My patients don t want to go to a psychiatrist/counselor/etc they just want to see me Would you be their oncologist or surgeon just because they felt nervous talking to a new doctor? By trying to be their psychiatrist / therapist / case manager you may be preventing them from getting the care they really need and putting yourself at risk. Availability-Liability CYA document not suicidal/homicidal at each visit Document that you referred patient to. Or recommended Be a broken record, give a clear and consistent message each visit Write on a prescription: make appointment with case manager, etc.
39 My opinion: Family practice doctors are some of the kindest people in the world. Set limits with your time This is exactly the sort of thing that is important for you to talk about with a counselor. I only have minutes to spend with each patient, so I don't have time for these sorts of in depth discussions. Dr. Phil You teach people how to treat you. Take good care of yourselves so you can take care of others!