Depressive Disorders Inpatient Management v.1.1 Executive Summary Citation Information Explanation of Evidence Ratings Summary of Version Changes Intake Admission interview, physical exam, and review of systems likely presence of a depressive disorder (e.g., Major Depression, Depression Not Otherwise Specified, Dysthymia, Adjustment Disorder with Depressed Mood). Admitting provider orders depressive disorders clinical pathway for eligible patients (see inclusion and exclusion criteria.) Inclusion Criteria Children and adolescents who are cognitively intact, age 10 years, with a depressive disorder Exclusion Criteria Mania, psychosis, and/or developmental delay Diagnostic Formulation and Psychoeducation Contact outpatient providers for collateral information. Administer empirically validated self-report questionnaires of depressive and other associated symptoms (e.g., anxiety). Clinical interview of patient and caregiver. Review and consider medical findings (e.g., PE, ROS, and lab testing) in formulating diagnosis. Consider consultation from appropriate medical services as clinically indicated. Psychoeducation related to specific diagnosis, including symptoms, prevalence, incidence, course, beneficial treatments, and prognosis. Admit Criteria Imminent risk for injury to self or others Active psychiatric disorder Acute deterioration from baseline, preventing fulfillment of developmentally-appropriate responsibility Treatment Evidence Summary Medication Evaluation or Adjustment Depressive Disorder Skills for Patients Depressive Disorder Skills for Caregivers Crisis Prevention Planning with Patient and Caregiver Assess potential benefit of a medication trial or adjustment of current medication(s) Complete psychoeducation and teaching related to medication Obtain consent for initiating a trial of a new medication Individual or Small Group Chain Analysis of Problem Behavior Mood Monitoring and Activity Charting Automatic Thoughts and Cognitive Distortions Therapeutic milieu Emotion regulation skills Distress tolerance skills Individual or Small Group Escalation Cycle and Safety Planning Review of patient Chain Analysis and Skills Therapeutic milieu Caregivers are encouraged to participate in general parent discussion groups offered through the Parent Support Program. Individual: Develop CPP considering triggers, warning signs, strategies for caregivers, skills for patients, and other psychosocial supports Therapeutic milieu DT Boxes School re-entry rehearsal Discharge Criteria No longer meets medical necessity for ongoing hospitalization (assessed daily) Acute crisis has subsided Completed safety components of the pathway Discharge Instructions Follow-up with outpatient providers Use crisis prevention plan Parents administer medications as directed Resume normal activities with appropriate supervision Implement safety recommendations For questions concerning this pathway, contact: PBMU_Pathways@seattlechildrens.org 2015 Seattle Children s Hospital, all rights reserved, Medical Disclaimer Last Updated: June 2012 Next Expected Revision: June 2017
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Title: Depressive Disorders Pathway Authors: Seattle Children s Hospital Kelly Schloredt Leslie Curran Jennifer Hrachovec Michael Leu Date: June 2012 Depressive Disorders Citation Retrieval Website: http://www.seattlechildrens.org/pdf/disruptive-behavior-disorders-pathway.pdf Example: Seattle Children s Hospital, Schloredt K, Curran L, Hrachovec JB, Leu M. 2012 June. Depressive Disorders Pathway. Available from:http://www.seattlechildrens.org/pdf/disruptive-behavior-disorderspathway.pdf Return to Home
Evidence Rating This pathway was developed through local consensus based on published evidence and expert opinion as part of Clinical Standard Work at Seattle Children s. Pathway teams include representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical Effectiveness, and other services as appropriate. When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.): Quality ratings are downgraded if studies: Have serious limitations Have inconsistent results If evidence does not directly address clinical questions If estimates are imprecise OR If it is felt that there is substantial publication bias Quality ratings are upgraded if it is felt that: The effect size is large If studies are designed in a way that confounding would likely underreport the magnitude of the effect OR If a dose-response gradient is evident Guideline Recommendation is from a published guideline that used methodology deemed acceptable by the team. Expert Opinion Our expert opinion is based on available evidence that does not meet GRADE criteria (for example, case-control studies). To Bibliography Return to Home
Summary of Version Changes Version 1.0 (6/20/2012): Go live Version 1.1 (5/13/2015): Updated Inpatient Psychiatry Unit to Psychiatry and Behavioral Medicine Unit Return to Home
Medical Disclaimer Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor Seattle Children s Healthcare System nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information. Readers should confirm the information contained herein with other sources and are encouraged to consult with their health care provider before making any health care decision. Return to Home
Bibliography Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian. Searches were performed on December 19, 20, 21 and 30th, 2011 in the following databases: on the Ovid platform Medline (1996 to date), Cochrane Database of Systematic Reviews (2005 June 2011),; elsewhere National Guidelines Clearinghouse, Clinical Evidence, and TRIP. Retrieval was limited to English language, literature from 2001-forward, children 0-18. As per the owners request, the search was focused on the treatment/diagnosis of major depression or dysthymia. In Medline, appropriate Medical Subject Headings (MeSH) were used, along with text words, and the search strategy was adapted for other databases using their controlled vocabularies, where available, along with text words. Only synthesized, high levels of evidence were included. Scout Search publication limits of consensus development, guidelines, meta-analyses, multi-center and practice guidelines were used. Jamie Graham, MLS April 26, 2012 Identification 192 records identified through database searching 1 additional records identified through other sources Screening 183 records after duplicates removed 183 records screened 99 records excluded Eligibility Included 85 records assessed for eligibility 63 full-text articles excluded, 4 did not answer clinical question 19 did not meet quality threshold 40 outdated relative to other included study 13 studies included in pathway Return to Home To Bibliography Pg 2
Bibliography Birmaher B, Brent D. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. http://www.ngc.gov/ content.aspx?id=11404&search=major+depression. Updated 2007. Accessed 12/21, 2011. Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque D, Stein RE. Guidelines for adolescent depression in primary care (GLAD-PC): II. treatment and ongoing management. http:// www.ngc.gov/content.aspx?id=12208&search=major+depression. Updated 2007. Accessed 12/21, 2011. Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). screening of children and adolescents for major depressive disorder (MDD). http://www.ngc.gov/ content.aspx?id=16308&search=major+depression. Updated 2010. Erford BT, Erford BM, Lattanzi G, et al. Counseling outcomes from 1990 to 2008 for school-age youth with depression: A meta-analysis. Journal of Counseling & Development [depression]. 2011;89(4):439-457. Accessed 12/19/2011 3:08:29 PM. Hazell D. Depression in children and adolescents. http://clinicalevidence.bmj.com/ceweb/conditions/ chd/1008/1008.jsp. Henken T, Huibers JHM, Churchill R, Restifo KK, Roelofs JJ. Family therapy for depression. Cochrane Database of Systematic Reviews [depression]. 2011;1. Accessed 12/20/2011 6:07:47 PM. National Collaborating Centre for Mental Health. Depression. The treatment and management of depression in adults. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Oct. 64 p. (Clinical guideline; no. 90). Jorm AF, Morgan AJ, Hetrick SE. Relaxation for depression. Cochrane Database of Systematic Reviews [depression]. 2009;1. Accessed 12/20/2011 6:07:47 PM. Larun L, Nordheim LV, Ekeland E, Hagen KB, Heian F. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database of Systematic Reviews [depression]. 2009;1. Accessed 12/20/2011 6:07:47 PM. New Zealand Guidelines Group. Identification of common mental disorders and management of depression in primary care. http://www.ngc.gov/ content.aspx?id=12994&search=dysthymic+disorder. Updated 2008. Accessed 12/21, 2011. US Preventive Services Task Force. Screening and treatment for major depressive disorder in children and adolescents: U.S. preventive services task force recommendation statement. http://www.ngc.gov/content.aspx?id=14294&search=major+depression. Updated 2009. Accessed 12/21, 2011. Williams SB, O'Connor EA, Eder M, Whitlock EP. Screening for child and adolescent depression in primary care settings: A systematic evidence review for the US preventive services task force. Pediatrics [depression]. 2009;123(4):e716-e735. Accessed 12/19/2011 3:08:29 PM. Zuckerbrot RA, Cheung AH, Jensen PS, Stein RE, Laraque D. Guidelines for adolescent depression in primary care (GLAD-PC): I. identification, assessment, and initial management. http:// www.ngc.gov/content.aspx?id=12207&search=major+depression. Accessed 12/21, 2011. To Bibliography Pg 1 Return to Home