Kristie Ladegard, MD, Denver Health Child Psychiatrist At 7 School Based Health Centers (SBHC) in Denver, CO Family Crisis Center (FCC) Substance Abuse Treatment Education & Prevention program (STEP) Outpatient Behavioral Health Scot McKay, MD, Denver Health Child Psychiatrist At 6 School Based Health Centers (SBHC) in Denver, CO Family Crisis Center (FCC) Outpatient Behavioral Health Presented by: Kristie Ladegard, MD Scot McKay, MD Heather Showman, LCSW Heather Showman, LCSW, Denver Health Mental Health Therapist Place Bridge School Based Health Center The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose 1987-Denver Health received a grant to open the first School Based Health Center at Abraham Lincoln, in Denver, CO. As of 2015 we have 16 SBHCs in the City and County of Denver, CO with 1 more clinic scheduled to open for 2015/2016 school year. Every student enrolled in the Denver Public School system has access to either their community school clinic or 3 regional clinics. Siblings of DPS students also eligible for services. Collaborative effort within the community including Denver Health, Denver Public Schools, Mental Health Center of Denver, and Jewish Family Services. Review/understand epidemiology of depression Introduce PHQ-9 Depression Screening Process Discuss outcomes and treatment recommendations 1
https://www.youtube.com/watch?v=vck2vbo zr9e&feature=player_detailpage 15 year old female Visited the clinic Nurse Practitioner complaining of frequent stomachaches in 12/2013 Upon encounter reported excessive sleep, feeling irritable most days, recent drop in grades and attendance, loss of motivation. 4% to 8% in adolescents with male to female ratio of 1:2 2% in children with male to female ratio of 1:1 Risk of depression increases by a factor of 2 to 4 after puberty especially in females Cumulative incidence by 18 is 20% in community samples 5%-10% of children and adolescents have subsyndromal symptoms of MDD (Major Depressive Disorder) MDD is the leading cause of disability among young people aged 10-24. 2 < 50% of youth with MDD seek treatment 3 48.3% of adolescents with MDD report that it severely impaired their ability to function in at least 1of 4 areas of their lives (home, school/work, family relationships, and social life). 4 Adolescents reporting the most severe impairment were unable to carry out normal activities on an average of 58.4 days in the past year. 4 2
Anxiety Disorders Disruptive Disorders MDD ADHD Substance use disorders Symptoms of Depression Depressed Mood Sleep problems Interest loss Guilt, worthlessness, hopelessness Energy loss Concentration Difficulties Appetite change Psychomotor Suicidality Signs of Depression in Youth Irritable or cranky mood Delays in falling asleep, refusal to wake for school Boredom, loss of interest in sports, video games, giving up favorite activities Self-critical no one likes me, everyone hates me, feels stupid Persistently tired, feels lazy Decline in performance in school due to decreased motivation and ability to concentrate, frequent absences Failure to gain weight, or overeating and weight gain especially in teens Difficulty sitting still, pacing, or very slowed down Frequent thinking & talking about death; writing about death, giving away favorite toys or belongings. Maintain a confidential relationship with the child/adolescent while developing collaborative relationships with parents, school staff, etc. Screen all youth for depressive symptoms If the screen is positive determine the presence of depressive and other comorbid psychiatric and medical disorders. 3
Assess for the presence of ongoing or past exposure to negative events such as: physical or sexual abuse neglect living in poor neighborhoods exposure to violence Obtain family history Always evaluate for the presence of harm to self and/or other Determine the level of care and intensity of treatment needed Nonsuicidal self-injury (NSSI) o 13%-23% lifetime prevalence o often begin age 13-15 o cutting and hitting most common o high risk for suicide and suicide attempts 70 % of adolescents who engaged in NSSI had made at least 1 suicide attempt o risk factors include: depression, substance use, anxiety, impulsive aggression, and history of trauma Interview adolescent alone Obtain collateral information from parents, teachers etc. Be empathetic and nonjudgmental Inquire about suicidal intent: extent of desire to carry out suicidal thoughts and die Note appearance of scarring, bruises and patient s clothing style Ask about acute stressors (i.e. break up, conflict with parents etc.) 4
Explore thoughts, feelings, end events leading up to SIB Assess for psychosis and homicidal thoughts. If yes assess whether there is a duty to warn Ask about drug/alcohol use Assess family interaction and communication style, noting conflicts that might impact safety Determine level of care Suicide Intent is to die Feel hopeless/helpless Feel no better after attempt Usually one primary method used High lethality NSSI (Nonsuicidal Self- Injury) Intent is to feel alive and avoid suicide May have periods of hope Usually experience relief after the attack Multiple methods used Low lethality Intent to end one s life includes ideation (thoughts) and actions (nonfatal or fatal attempts). 5 Suicide is 3 rd leading cause of death among youths 10--24 y/o; accidents and homicides are the first and second. 7 1 in 5 U.S. high school students have suicidal thoughts each year, and 1 in 10 attempt suicide. 5 Girls are more likely to attempt suicide but male youth die by suicide five times more frequently than females. 7 Up to 76% had contact with their PCP in the month prior to their suicide and are more than twice as likely to have seen their PCP rather than a mental health professional. 8 5
20 18 16 14 12 10 8 6 4 2 0 Suicide Rate by Race ages 15-24, 2011 17.72 12.10 6.95 6.32 5.46 11.01 Series 1 Always ask about suicidal thoughts, intent, and behaviors. Asking does not increase suicidal thoughts or behaviors. 5 Interview adolescent separately from parents. Use an empathic, nonjudgmental manner Identify risk factors Identify protective factors/available resources If risks > available resources consider a higher level of care Suicidal thoughts: frequency, duration, plans and triggers Suicide intent: extent of desire to carry out suicidal thoughts and die, organized plan? Past suicide attempts: #of attempts, methods, intentions, and consequences Nonsuicidal self-injury: total episodes, duration, frequency, and triggers History of psychiatric disorders Substance use Assess social network including family interaction and communication style, is there a family history of suicide? Access to lethal means such as firearms Ask about acute stressors such as break-up, loss or rejection, conflict with parents, divorce of parents Assess for psychosis and homicidal thoughts 6
A good parent-child relationship Strong cultural or religious values An intact family A sense of connection with peer group and school Academic achievement Limited access to firearms There are several scales or tools that may help to assess risk and determine whether a higher level of care may be needed. However, none of these scales/tools can predict suicide and they are not a substitute for a thorough clinical assessment. 9 Some examples include PHQ-9, Sad Person scale, Scale for Suicidal Ideation, Is Path Warm scale 10 Adolescent Confidential Health History Marked yes to four of nine depression screening questions 7
All students 6 th grade and higher complete Adolescent Confidential Health History, regardless of reason for visit 53 questions regarding physical and mental health, family health history, psychosocial assessment, etc. Provided confidentially, away from parents, to increase likelihood of honest responses English and Spanish languages offered in all clinics 13 questions address possible Depression Yes response to depression questions indicates PHQ-9 follow-up Review your Adolescent Confidential Health History handouts Which screening questions might be used to screen for depression in teens? 8
9 numerically scored questions; 4 yes/no questions Score 0-4 PCP discretion, not entered in registry Score 5-27 follow-up, entered in registry Score 5-9 re-assessed within one month, PCP discretion for additional services Score 10-19, entered in registry as Clinically Significant Depression, patient preference for medication/psychotherapy or both Score >20, entered in registry as Clinically Significant Depression, combination of psychotherapy and medication recommended Any yes response to questions, highly recommended referral to mental health team for Mental Health Screening Nine numerically scored questions Database tracks History of scores Type of encounter Inclusion of suicide risk assessment Family involvement Therapy involvement Medications administered 9
12/9/2013-prescribed Prozac 1/9/2014-medication switched to Wellbutrin XL 1/30/14-Mental Health Intake, PHQ-9 score of 14, Weekly individual psychotherapy initiated B.A.T.H.E. Background- What is going on in your life? Affect- How do you feel about that? Trouble- What troubles you the most about this issue? Handle- How are you handling it? Empathy- express empathy for their situation see handout for additional CBT techniques N = 439; 12-17 year olds; MDD Randomized into fluoxetine (FLX) plus CBT, CBT alone, FLX alone, or placebo 12 weeks of treatment followed by 24 week continuation (placebo was unblinded at week 12 and treated as indicated) Findings: Combo (71%) > FLX (60.6%) > CBT (43.2%) = placebo (34.8%) Suicidal ideation greatest in FLX group At 18 weeks, CBT = FLX Average dose FLX, 28.4mg in combo group and 33.3mg in FLX alone group N = 326; 12-18 year olds MDD who did not respond to 8 weeks of SSRI treatment Randomization arms: 1) switch to another SSRI (fluoxetine or citalopram) 2) switch to venlafaxine 3) switch to another SSRI plus CBT 4) switch to venlafaxine plus CBT 12 weeks of treatment followed by 12 week continuation Findings: Combo > med alone SSRI = venlafaxine 10
Start with an SSRI Prozac (fluoxetine) Zoloft (sertraline) Celexa (citalopram) Lexapro (escitalopram) Switch to another SSRI or Wellbutrin (buproprion) Effexor (venlafaxine) Combine SSRI / SNRI / Buproprion or augment with Lithium Levothyroxine Atypical antipsychotic Fluoxetine Start at 10mg, increase to 20mg at week 2, target dose 20-60mg (average is 30mg) Sertraline Start at 12.5-25mg, increase to 25-50mg at week 2; increase again at week 5; target dose 50-200mg (average is 75mg) Citalopram Start at 10mg, increase to 20mg at week 2, up to 40mg at week 5 if needed; new FDA warning of increased QT over 40mg Escitalopram Start at 5mg, increase to 10mg at week 2; up to 20mg if needed Venlafaxine (Recommend XR) Start 37.5mg, increase to 75mg at week 2 and then to 150mg at week 4; increase up to 225mg/day Noradrenergic at higher doses >150mg Buproprion (Recommend XL) Start at 150mg and increase to 300mg at week 4 Issued by FDA in 2004 from paroxetine (Paxil) study data done in the UK 4% SI on paroxetine and 2% SI on placebo No completed suicides in the study Prescribing of SSRI dropped 20% and suicide rate increased Meta-analysis (Bridge, et al JAMA 2007) showed NNH is 112 Worst offenders: paroxetine and venlafaxine (Effexor) Recommend return visit in 1-2 weeks after starting medication to assess for increased suicidal ideation 11
Side effects usually resolve after 1st week of treatment Start low and go slow Full effect is in 4-6 weeks Recommend 6-12 month trial period Kids have more efficient metabolism and may need BID dosing If concerned about potential Bipolar disorder, stay away from fluoxetine which has a 72 hour half life Sertraline tends to be more sedating, fluoxetine tends to be more energizing, and citalopram tends to be neutral Cytochrome 2D6, fluoxetine is a potent inhibitor Gender Male 40% Female 60% Race Hispanic 51% African American 5% Caucasian 8% Other 36% Medications and/or Therapy Therapy alone 30% in August to 61% by July Max of 63% in November and 62% in March and April Medication alone 20% in August to 21% by July Max of 22% in March and April Medication plus therapy 20% in August to 18% by July Max of 20% in August and March None 40% in August to 20% by July Seasonality Treatment highest in March and April with November not far behind Family Involvement Increases over the year from 50% to 57% but interestingly lowest in November (40%) which is a height in treatment rate 12
August 2013 to November 2015 Absenteeism Test scores Suspensions / discipline 13
http://www.dsm5.org/pages/default.aspx http://www.palforkids.org/ http://www.jedfoundation.org/ http://www.halfofus.com/ http://www.healthyminds.org http://www.aacap.org/ Kristie.ladegard@dhha.org Scot.mckay@dhha.org Heather.showman@dhha.org 1 American Academy of Child and Adolescent Psychiatry (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. Journal of the American Academy of Child and Adolescent Psychiatry (46)11 (1503-1526). 2 Gore F, Bloem P, Patton G, et al. (2011), Global burden of disease in young people aged 10-24 years: A systematic analysis. Lancet 377:2093 2102. 3 Reavley NJ, Cvetkovski S, Jorm AF, Lubman DI. (2010) Help-seeking for substance use, anxiety, and affective disorders among young people: results from the 2007 Australian National Survey of Mental Health and Wellbeing. Australian & New Zealand Journal of Psychiatry Aug;44(8):729-35. 4 http://oas.samhsa.gov/2k8/youthdepress/youthdepress.cfm. 5 Peterson J, Freedenthal S, Coles A, (2010), Adolescents who self-harm: How to protect them from themselves. Current Psychiatry Aug ;9(8)1-8 6 Brickell C. Jellinek M. Self injury: Why teens do it, how to help. Contemporary Pediatrics. March 1, 2014. Accessed at: http://contemporarypediatrics.modernmedicine.com/contemporarypediatrics/content/tags/borderline-personality-disorder/self-injury-why-teens-do-ithow. 7 American Association of Suicidology. (2011). Youth suicidal behavior fact sheet. Accessed at www.suicidology.org/web/guest/stats-and-tools/fact-sheets 8 Taliaferro, L.A., Borowsky I.W., (2011). Perspective: Physician education: A promising strategy to prevent adolescent suicide. Academic Medicine, 86 (3), 342 9 American Academy of Child and Adolescent Psychiatry, (2001) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behavior. Journal of the American Academy of Child and Adolescent Psychiatry (40)7 24-51 10 Franklin Cynthia, Harris Mary Beth, Allen-Meares Paula (2013) The School Services Sourcebook: A Guide for School-Based Professionals. Franklin C, Harris, MB, Allen- Meares, P, eds. New York: Oxford University Press 11 Clabby JF. Helping depressed adolescents: A menu of cognitive-behavioral procedures for primary care. Prim Care Companion J Clin Psychiatry. 2006; 8(3): 131-41. 12 Treatment for Adolescents with Depression Study (TADS) Team. Fluoxetine, cognitivebehavioral therapy, and their combination for adolescents with depression: Treatment for adolescents with depression study (TADS) randomized controlled trial. JAMA. 2004; 292(7): 807-820. 13 Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: The TORDIA randomized controlled trial. JAMA. 2008; 299(8): 901-913. 14 Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007; 297(15): 1683-96. 14