GLAD-PC Steering Group Releases Guidelines for the Management of Adolescent Depression in Primary Care
Am Fam Physician. 2008 Sep 1;78(5):652-654.
Guideline source: GLAD-PC Steering Group
Literature search described? Yes
Evidence rating system used? Yes
Published source: Pediatrics, November 2007
Although major depression in adolescents is a serious psychiatric illness, only one half of those affected are correctly diagnosed before adulthood, and only one third will be identified by their primary care physician and receive treatment. Because adolescents often lack access to mental health professionals, primary care physicians should be prepared to diagnose and manage depression in this population. The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Steering Group developed these guidelines, which are the first evidence-based, expert consensus-derived guidelines for the management of adolescent depression by primary care physicians.
Physicians should identify patients with risk factors for depression and monitor them for the development of a depressive disorder. Because difficulties with psychosocial functioning in adolescents could indicate a variety of problems, physicians should routinely monitor the psychosocial functioning of their patients using systematic identification strategies. Risk factors for depressive disorders include personal or family history of depression, bipolar disorder, suicide-related behaviors, substance abuse, or other psychiatric illnesses; or significant psychosocial stressors (e.g., physical abuse, neglect). Evaluation for depression should occur at least once a year. Evaluation tools for high-risk patients include standardized written instruments (e.g., symptom checklists, questionnaires, validated depression scales) and interviews.
Assessment and Diagnosis
Physicians should evaluate adolescent patients for depression if they are at high risk or if emotional problems are the chief complaint. Symptom assessment should be based on diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., or the International Classification of Diseases, 10th rev. Standardized depression tools can be used to aid in assessment. Adolescents who have depression may not be able to identify depressed mood as their presenting complaint; therefore, physicians should be aware of common symptoms of major depressive disorder (e.g., insomnia, weight loss, family conflict). Standardized instruments can be used to aid in the diagnosis, but should not replace direct interview by the physician.
Interviews with patients and their families and evaluation of functional impairment in various settings should be included in the assessment of depression. Family involvement in all phases of depression management is critical. Family relationships, as well as cultural background, can affect the presentation and symptoms of depression in adolescents. Evidence of symptoms and functional impairment should be obtained from the patient and family separately. Information from other sources, including teachers, could also be helpful. Comorbid conditions, functional impairment, and subjective distress should be evaluated, and a safety assessment performed.
Patients and their families should receive counseling and education about depression, as well as a review of their management options. Physicians should also discuss the limits of confidentiality with them. Information about causes and symptoms of depression, impairments associated with depression, and expected treatment outcomes should be presented in a way that patients and their families can understand. Cultural factors that can affect diagnosis or management should be taken into account. Because depression can affect many areas of a patient's life, a partnership should be developed with personnel at the patient's school and other settings (e.g., extracurricular activities). The patient and family should be made aware of the limits of confidentiality, including the need to involve parents if there is an imminent risk of harm to the patient or others. Physicians should be familiar with their state laws regarding confidentiality.
Physicians, along with patients and their families, should develop a treatment plan with specific goals in main areas of functioning (e.g., home, school, peer settings).Studies have shown that identifying and tracking goals and outcomes of treatment is associated with better adherence; the patient and family should participate in determining goals and desired outcomes at the start of treatment. Monitoring of the patient's adherence and clinical status by a case manager may be beneficial.
Physicians should collaborate with mental health resources in their area. Collaborating with other mental health resources helps ensure timely and effective access to services. This may include working with other patients and families who have experienced adolescent depression and are willing to help other affected adolescents and families. Physicians should also establish relationships with paraprofessionals who may provide most of the counseling and support services in underserved areas.
Management of depression should involve a safety plan that includes restriction of lethal means, bringing in a concerned third party, creating a means of communication in emergencies (e.g., if a patient deteriorates, becomes suicidal or a threat to others, or experiences an acute crisis associated with psychosocial stressors). Suicidality is common in adolescents with depression; one study showed that more than 50 percent of persons who commit suicide have a diagnosis of depression. Physicians should develop a way to communicate with family and appropriate personnel in case of emergency for patients who have increased suicidality or acute crises. When evaluating a patient for suicidality, the physician should obtain a third-party opinion; determine that the patient is adequately supervised and has access to support; have an adult assist in removing firearms and potentially lethal medications from the premises; warn the patient about the disinhibiting effects of drugs and alcohol; decide on a contingency plan; and establish follow-up within a reasonable period of time. Parts of this safety plan may include a list of contacts who know the adolescent, are familiar with his or her problems, and can help in a time of crisis. Establishing this plan is especially important in the beginning stages of diagnosis and treatment because this is when concerns about safety are highest.
After initial diagnosis in patients with mild depression, physicians should consider a period of monitoring and support before initiating other treatments. Active monitoring may include six to eight weeks of once or twice weekly visits. Randomized controlled trials have shown that many patients respond to nondirective supportive therapy and regular monitoring. If the patient's symptoms persist, treatment with psychotherapy or antidepressants should be offered. Support and monitoring are important, especially in patients or families who refuse other treatments. If a patient has moderate to severe depression, the physician should recommend immediate treatment, crisis intervention (if needed), and consultation with a mental health professional, without a monitoring period.
Consultation with a mental health professional should be considered in patients with moderate to severe depression or complicating factors (e.g., substance abuse, psychosis). Mental health professionals and physicians should work together to determine their appropriate roles and responsibilities in treating patients. Patients and their families should approve these roles. Consultation with a mental health professional should be based on physician judgement, preferences of the patient and family, severity of the disease, and physician training and expertise. Physicians should consider consultation with or referral to mental health professionals for patients with severe depression or comorbid conditions. For patients with moderate depression, physicians should consider consultation with a mental health professional or treatment in the primary care setting. Active support and treatment should be initiated when there are long waits for mental health services. The physician and mental health professional should discuss and agree on their roles and responsibilities, as well as decide which of them should be responsible for case coordination.
If possible and appropriate, physicians should recommend tested and proven treatment options, including psychotherapies (e.g., cognitive behavior therapy [CBT], interpersonal psychotherapy [IPT]), antidepressants (e.g., selective serotonin reuptake inhibitors [SSRIs] ). Effective treatment methods, including medication, psychotherapy, and family support, should be considered, and the patient and family should assist in planning a treatment that is implementable and that takes into account their preferences and the availability of treatment services. Treatment decisions should be based on disease severity, risk of suicide, and existence of comorbid conditions. As time passes, new treatments may become available; however, common sense approaches (e.g., adequate nutrition, exercise) should continue to be used in managing depression.
CBT and IPT have been shown to be effective for treating adolescents with depression in tertiary care and community settings. Preliminary study results have shown that CBT is useful in the primary care setting. Combination therapy with medication and CBT has been found to be more effective than CBT alone.
If an SSRI is used, drug selection should be based on safety and effectiveness. The patient and family should be told about possible adverse effects, including development of behavioral activation or suicidal behavior. Once the medication is started, the physician should ensure an adequate trial up to the maximal dosage and treatment duration. Effective dosages of SSRIs for depression in adolescents are lower than those found in guidelines on adult depression. Of note, the U.S. Food and Drug Administration (FDA) has approved only fluoxetine (Prozac) for use in children and adolescents with depression.
Patients should be monitored for adverse effects during antidepressant treatment. The FDA recommends that adolescents treated with antidepressants be monitored for clinical worsening, suicidality, and unusual behavior changes. Monitoring is especially important during the first few months of treatment and after dosing changes. Evidence is lacking about how often monitoring should be done, but the FDA recommends at least weekly face-to-face meetings with the patient and family in the first four weeks of treatment, biweekly meetings until 12 weeks, and then as clinically indicated beyond 12 weeks. Telephone contact between meetings may also be appropriate.
Goals and outcomes of treatment should be systematically and regularly tracked. Treatment goals should include improving function and resolving symptoms. Tracking these goals and outcomes should include patient functioning in several settings, such as at home and at school. Evidence has shown that functional impairment and depressive symptoms may not improve at the same rate with treatment; therefore, regular tracking should occur throughout treatment, with information collected from patients and their families when possible.
Patients should be seen within one week of the start of treatment, and physicians should ask about symptoms, suicide risk, adverse effects, treatment adherence, and environmental stressors. Evidence suggests that treatment with antidepressants should be continued for one year, and the GLAD-PC and the American Academy of Child and Adolescent Psychiatry experts recommend that medication be maintained for six months to one year after symptoms have fully resolved. If a depressive episode is a recurrence, physicians are encouraged to monitor patients for up to two years. Consultation with a mental health professional should be obtained if the patient develops new or worsening comorbid conditions, psychosis, or suicidal or homicidal ideation.
If no improvement is seen after six to eight weeks of treatment, physicians should reassess the diagnosis and treatment plan, and should consider consultation with a mental health professional. Evidence of improvements may include reduced symptoms or improved functioning in school or social settings. The physician should reassess the initial diagnosis, treatment plan, adherence, comorbid conditions that affect treatment, and new external stressors. If the patient does not respond to the maximal dosage of medication, the physician should consider changing the medication. Likewise, if the patient fails to improve on medication or therapy alone, the physician should consider adding or switching to another treatment modality.
Consultation with a mental health professional should be considered in patients who show only partial improvement after all options for diagnosis and treatment have been explored. The physician should review the diagnosis and evaluate causes of the partial response (e.g., poor adherence, comorbid conditions, abuse). The causes may need to be addressed before changes to the treatment plan are made. If the patient has shown partial improvement after taking the maximal tolerated dosage of SSRI, psychotherapy should be considered (if it has not been previously conducted). Other considerations include adding or switching medication or increasing dosages above FDA-approved ranges. If a patient fails to improve on CBT or IPT and has not yet tried medication, a trial of SSRIs should be considered. The physician should also consider referral to a mental health professional.
To ensure adequate management, physicians should continue to support patients who are referred to a mental health professional. They should also consider sharing care of the patient with the mental health professional. Follow-up by the primary care physician should be continued in patients who have been referred to a mental health professional and, if possible, sharing treatment of the patient should be considered. There has been evidence of greater effectiveness of treatment with “shared-care” models in adults with depression in the primary care setting. Similar evidence is emerging in case reports on adolescents.
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