ADOLESCENT DEPRESSION: Help your patient emerge from the darkness

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Applied Evidence

ADOLESCENT DEPRESSION: Help your patient emerge from the darkness

J Fam Pract. 2009 May;58(5):257-264

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References

1. Zuckerbrot RA, Cheung A, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care–GLAD PC – Part I. Pediatrics. 2007;120:e1299-e1312.

2. Richardson LP, Lewis CW, Casey-Goldstein M, et al. Pediatric primary care providers and adolescent depression. J Adolesc Health. 2007;40:433-439.

3. Myers SS, Phillips RS, Davis RB, et al. Patient expectations as predictors of outcome in patients with acute low back pain. J Gen Intern Med. 2008;23:1525-1497.

4. Aikens JE, Nease DE, Jr, Nau DP, et al. Adherence to maintenance-phase antidepressant medication as a function of patient beliefs about medication. Ann Fam Med. 2005;3:23-30.

5. Brent DA, Perper JA, Moritz G, et al. Psychiatric risk factors for adolescent suicide: a case-control study. J Am Acad Child Adolesc Psychiatry. 1993;32:521-529.

6. American Academy of Child and Adolescent Psychiatry. Summary of the practice parameters for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry. 2001;40:495-499.

7. Cheung A, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care–GLAD PC – Part II. Pediatrics. 2007;120:e1313-e1326.

8. Cheung AH, Zuckerbrot RA, Jensen PS, et al. Expert survey for the management of adolescent depression in primary care. Pediatrics. 2008;121:e101-e107.

9. Compton SN, March JS, Brent D, et al. Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. J Am Acad Child Adolesc Psychiatry. 2004;43:930-959.

10. Mufson L, Weissman MM, Moreau D, et al. Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 1999;56:573-579.

11. Mufson L, Dorta KP, Wickramaratne P, et al. A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Arch Genl Psychiatry. 2004;61:577-584.

12. Clarke GN, Rohde P, Lewinsohn PM, et al. Cognitive-behavioral treatment of adolescent depression: efficacy of acute group treatment and booster session. J Am Acad Child Adolesc Psychiatry. 1999;38:272-279.

13. Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial. JAMA. 2005;293:311-319.

14. Clarke G, Debar L, Lynch F, et al. A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. J Am Acad Child Adolesc Psychiatry. 2005;44:888-898.

15. March 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;292:807-820.

16. Mufson L, Moreau D, Weissman M. Interpersonal Psychotherapy for Depressed Adolescents. New York: Guildford Press; 2004.

17. Olson AL, Kelleher KJ, Kemper KJ, et al. Primary care pediatricians’ roles and perceived responsibilities in the identification and management of depression in children and adolescents. Ambul Pediatr. 2001;1:91-98.

18. 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;297:1683-1696.

19. Mayes TL, Tao R, Rintelmann JW, et al. Do children and adolescents have differential response rates in placebo-controlled trials of fluoxetine? CNS Spectr. 2007;12:147-154.

20. Birmaher B, Brent D. And the AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:1503-1526.

GLAD-PC Recommendation I: Family physicians should educate and counsel families and patients about depression and options for the management of the disorder (strength of recommendation [SOR]: C, expert opinion). Family physicians should also discuss the limits of confidentiality with the adolescent and family (SOR: C, expert opinion).

GLAD-PC Recommendation II: Family physicians should develop a treatment plan with patients and families (SOR: C, expert opinion) and set specific treatment goals in key areas of functioning, including home, peer, and school settings (SOR: C, expert opinion).

GLAD-PC Recommendation III: The family physician should establish relevant links/collaboration with mental health resources in the community (SOR: C, expert opinion), which may include patients and families who have dealt with adolescent depression and are willing to serve as resources to other affected adolescents and their family members (SOR: C, expert opinion).

GLAD-PC Recommendation IV: Management must include the establishment of a safety plan, which includes restricting lethal means, engaging a concerned third party, and implementing an emergency communication mechanism should the patient deteriorate, become actively suicidal or dangerous to others, or experience an acute crisis associated with psychosocial stressors, especially during the period of initial treatment when safety concerns are highest (SOR: C, case control study and expert opinion).

GLAD-PC Recommendation V: After initial diagnosis in cases of mild depression, family physicians should consider a period of active support and monitoring before starting other evidence-based treatments (SOR: C, expert opinion).

GLAD-PC Recommendation VI: If a family physician identifies an adolescent with moderate or severe depression or complicating factors/conditions such as co-existing substance abuse or psychosis, consultation with a mental health specialist should be considered (SOR: C, expert opinion). Appropriate roles and responsibilities for ongoing management by the family physician and mental health provider should be communicated and agreed upon (SOR: C, expert opinion).

The patient and family should be consulted and approve of the roles negotiated by the family physician and mental health professionals (SOR: C, expert opinion).

GLAD-PC Recommendation VII: Family physicians should recommend scientifically tested and proven treatments (eg, psychotherapies such as cognitive behavioral therapy or interpersonal therapy, and/or antidepressant treatment such as SSRIs) whenever possible and appropriate to achieve the goals of the treatment plan (SOR: A, RCTs).

GLAD-PC Recommendation VIII: Family physicians should monitor for the emergence of adverse events during antidepressant treatment (SSRIs) (SOR: C, expert opinion).

Treatment options: When active support is best

Selecting the appropriate treatment modality for your patient hinges, of course, on the severity of the teen’s depression. (For more information on how to determine the severity of a depressive episode, see the first installment of this series, “Adolescent depression: Is your young patient suffering in silence?” J Fam Pract. 2009;58:187-192.)

When caring for a patient like Jane who is suffering from mild depression, consider providing active support and monitoring during 6 to 8 weekly or biweekly visits before recommending antidepressant medication or psychotherapy. This approach is also indicated when depressed patients or their parents refuse other treatments.⁷

FAST TRACK

A sizable percentage of young people with depression respond to nondirective supportive therapy and regular symptom monitoring.

Active support and monitoring may include education, frequent follow-up, a prescribed regimen of exercise and leisure activities, referral to a peer support group, and review of self-management goals. Other resources for active monitoring can be found in the GLAD-PC toolkit (available at www.gladpc.org). Evidence from randomized controlled trials (RCTs) shows that a sizable percentage of young people with depression respond to nondirective supportive therapy and regular symptom monitoring.⁷ Furthermore, emerging data from the research literature, expert opinion, and patient and family preferences indicate that active support and monitoring from family physicians is an important therapeutic strategy.^7,8

Is therapy needed—and if so, what kind?

Adolescents with moderate or severe depression or patients with mild depression whose symptoms do not improve with active support and monitoring alone will likely require treatment with one of the evidenced-based treatments, such as psychotherapy or antidepressants. Referral to a mental health provider for further assessment or treatment may also be required, depending on the training of the physician.^7,8 If so, you and the mental health provider will need to negotiate your roles and responsibilities for ongoing management, with the input and approval of the patient and family.

Both cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) have been adapted to address major depressive disorder (MDD) in adolescents and have been shown to be effective in community as well as specialized settings.^9-11

CBT is time-limited and delivered individually or by 1 or 2 clinicians working with a group. Clinicians follow a manual to guide each session.¹² (A manual for therapists and a workbook for adolescents and parents can be downloaded from the Kaiser Permanente Center for Health Research Web site at http://www.kpchr.org/public/acwd/acwd.html.)