Childhood and adolescent depression: the role of primary care providers in diagnosis and treatment

Real-World Depression Screening Practices Among Primary Care Providers Across Patient-Level and Provider-Level Characteristics

This study examined primary care provider (PCP) alignment with guideline-based care for adolescent depression screening and identified factors associated with post-screening responses. A retrospective chart review was conducted across 17 primary care clinics. Logistical regressions were estimated across provider specialties, sociodemographic factors, and patient clinical histories. Significant differences in follow-up and identification of depression were found among patients with more severe depression presentation. Follow-up screening was also more likely to be completed among patients with private insurance and less likely to occur among Black patients. Patients with significant mental health history of a mood concern, history of being prescribed psychotropic medication, were currently on medications at the time of the screening, or had a history of an internal mental health referral had a higher predicted probability of being identified as depressed on the patient problem list.

Improving Primary Care Adolescent Depression Screening and Initial Management: A Quality Improvement Study

Although recommended, adolescent depression screening with appropriate initial management is challenging. This project aimed to improve adolescent depression screening rates during preventive care visits in 12 primary care clinics from 65.4% to 80%, increase the proportion of documented initial management for those with a positive screen from 69.5% to 85%, then sustain improvements for 12 months.

Preventive strategies for adolescent depression: What are we missing? A focus on biomarkers

Adolescent depression is an important global issue with several unmet needs that still must be addressed and, to date, there are only few effective preventive strategies to reduce the burden of this disorder worldwide. In this mini-review, the evidence and potential ways to improve an early detection will be discussed as well as prompt interventions by focusing on a better understanding of the risks underlying the developing of adolescent depression from both a sociodemographic and a biological perspective.

Finding Relevant Psychoeducation Content for Adolescents Experiencing Symptoms of Depression: Content Analysis of User-Generated Online Texts

Background

Symptoms of depression are frequent in youth and may develop into more severe mood disorders, suggesting interventions should take place during adolescence. However, young people tend not to share mental problems with friends, family, caregivers, or professionals. Many receive misleading information when searching the internet. Among several attempts to create mental health services for adolescents, technological information platforms based on psychoeducation show promising results. Such development rests on established theories and therapeutic models. To fulfill the therapeutic potential of psychoeducation in health technologies, we lack data-driven research on young peoples’ demand for information about depression.

Objective

Our objective is to gain knowledge about what information is relevant to adolescents with symptoms of depression. From this knowledge, we can develop a population-specific psychoeducation for use in different technology platforms.

Methods

We conducted a qualitative, constructivist-oriented content analysis of questions submitted by adolescents aged 16-20 years to an online public information service. A sample of 100 posts containing questions on depression were randomly selected from a total of 870. For analysis, we developed an a priori codebook from the main information topics of existing psychoeducational programs on youth depression. The distribution of topic prevalence in the total volume of posts containing questions on depression was calculated.

Results

With a 95% confidence level and a ±9.2% margin of error, the distribution analysis revealed the following categories to be the most prevalent among adolescents seeking advice about depression: self-management (33%, 61/180), etiology (20%, 36/180), and therapy (20%, 36/180). Self-management concerned subcategories on coping in general and how to open to friends, family, and caregivers. The therapy topic concerned therapy options, prognosis, where to seek help, and how to open up to a professional. We also found young people dichotomizing therapy and self-management as opposite entities. The etiology topic concerned stressors and risk factors. The diagnosis category was less frequently referred to (9%, 17/180).

Conclusions

Self-management, etiology, and therapy are the most prevalent categories among adolescents seeking advice about depression. Young people also dichotomize therapy and self-management as opposite entities. Future research should focus on measures to promote self-management, measures to stimulate expectations of self-efficacy, information about etiology, and information about diagnosis to improve self-monitoring skills, enhancing relapse prevention.

Depression in adolescence: a review

Background

Depression is a common mental health disease, especially in mid to late adolescence that, due to its particularities, is a challenge and requires an effective diagnosis. Primary care providers are often the first line of contact for adolescents, being crucial in identifying and managing this pathology. Besides, several entities also recommend screening for depression on this period. Thus, the main purpose of this article is to review the scientific data regarding screening, diagnosis and management of depression in adolescence, mainly on primary care settings.

Main body

Comprehension of the pathogenesis of depression in adolescents is a challenging task, with both environmental and genetic factors being associated to its development. Although there are some screening tests and diagnostic criteria, its clinical manifestations are wide, making its diagnosis a huge challenge. Besides, it can be mistakenly diagnosed with other psychiatric disorders, making necessary to roll-out several differential diagnoses. Treatment options can include psychotherapy (cognitive behavioural therapy and interpersonal therapy) and/or pharmacotherapy (mainly fluoxetine), depending on severity, associated risk factors and available resources. In any case, treatment must include psychoeducation, supportive approach and family involvement. Preventive programs play an important role not only in reducing the prevalence of this condition but also in improving the health of populations.

Conclusion

Depression in adolescence is a relevant condition to the medical community, due to its uncertain clinical course and underdiagnosis worldwide. General practitioners can provide early identification, treatment initiation and referral to mental health specialists when necessary.

The Michigan Child Collaborative Care Program: Building a Telepsychiatry Consultation Service

This column describes the establishment of the Michigan Child Collaborative Care (MC3), a statewide telepsychiatry consultation program that provides support to primary care providers (PCPs) in meeting the mental health needs of youths and perinatal women. The MC3 program provides cost-effective, timely, remote consultation to primary care providers in an effort to address the lack of access and scarcity of resources in child, adolescent, and perinatal psychiatry. Data from 10,445 service requests are summarized. Common diagnoses included attention-deficit hyperactivity disorder, mood disorders, anxiety disorders, and autistic spectrum disorders, with many cases (58%) deemed moderate to severe. Co-occurring psychological trauma was suspected in 9% of service requests. Partnerships, stakeholder roles, PCP engagement, and workflow integration are highlighted as keys to the program's success.

What were the impacts of the Committee on Safety of Medicines warning and publication of the NICE guidelines on trends in child and adolescent antidepressant prescribing in primary care? A population based study

OBJECTIVES

To assess the impact of both the Committee on Safety of Medicines (CSM) warning (December 2003) and the National Institute for Health and Care Excellence (NICE) guidance (September 2005) on antidepressant prescription rates in children and adolescents within the UK primary care service.

SETTING

Population based study of primary care antidepressant prescribing using the Clinical Practice Research Datalink (CPRD).

PARTICIPANTS

Under-18s presenting to primary care with a depressive disorder or related diagnostic code recorded in the CPRD.

PRIMARY OUTCOME MEASURE

Antidepressant prescription rates per month per 100 000 depressed 4-17 year olds.

RESULTS

Following the CSM warning, the prior trend towards increased prescribing rates for selective serotonin reuptake inhibitors (SSRIs) in children was significantly reversed (β for change in trend -12.34 (95% CI -18.67 to -6.00, p<0.001)). However, after the publication of the NICE guidelines the prior trend towards increased prescribing resumed for those SSRIs mentioned as potential treatments in the guidance (fluoxetine, citalopram and sertraline) (β for change in trend 11.52 (95% CI 5.32 to 17.73, p<0.001)). Prescribing of other SSRIs and tricyclics remained low.

CONCLUSIONS

Despite a strong emphasis on psychosocial interventions for child and adolescent depression, it may be that the NICE guidelines inadvertently encouraged further antidepressant prescribing, at least for those SSRIs cited. Although the guidelines gave cautions and caveats for the use of antidepressants, practitioners may have interpreted these recommendations as endorsing their use in young people with depression and related conditions. However, more accurate prevalence trend estimates for depression in this age group, and information on the use of psychosocial interventions would be needed to rule out other reasons underlying this increase in prescribing.

Developing a best practice pathway to support improvements in Indigenous Australians' mental health and well-being: a qualitative study

OBJECTIVE

There is a need to adapt pathways to care to promote access to mental health services for Indigenous people in Australia. This study explored Indigenous community and service provider perspectives of well-being and ways to promote access to care for Indigenous people at risk of depressive illness.

DESIGN

A participatory action research framework was used to inform the development of an agreed early intervention pathway; thematic analysis

SETTING

2 remote communities in the Northern Territory.

PARTICIPANTS

Using snowball and purposive sampling, 27 service providers and community members with knowledge of the local context and the diverse needs of those at risk of depression were interviewed. 30% of participants were Indigenous. The proposed pathway to care was adapted in response to participant feedback.

RESULTS

The study found that Indigenous mental health and well-being is perceived as multifaceted and strongly linked to cultural identity. It also confirms that there is broad support for promotion of a clear pathway to early intervention. Key identified components of this pathway were the health centre, visiting and community-based services, and local community resources including elders, cultural activities and families. Enablers to early intervention were reported. Significant barriers to the detection and treatment of those at risk of depression were identified, including insufficient resources, negative attitudes and stigma, and limited awareness of support options.

CONCLUSIONS

Successful early intervention for well-being concerns requires improved understanding of Indigenous well-being perspectives and a systematic change in service delivery that promotes integration, flexibility and collaboration between services and the community, and recognises the importance of social determinants in health promotion and the healing process. Such changes require policy support, targeted training and education, and ongoing promotion.

Magnetic seizure therapy in an adolescent with refractory bipolar depression: a case report

Magnetic seizure therapy (MST) has shown efficacy in adult patients with treatment-resistant depression with limited impairment in memory. To date, the use of MST in adolescent depression has not been reported. Here we describe the first successful use of MST in the treatment of an adolescent patient with refractory bipolar depression. This patient received MST in an ongoing open-label study for treatment-resistant major depression. Treatments employed a twin-coil MST apparatus, with the center of each coil placed over the frontal cortex (ie, each coil centered over F3 and F4). MST was applied at 100 Hz and 100% machine output at progressively increasing train durations. Depressive symptoms were assessed using the 24-item Hamilton Depression Rating Scale and cognitive function was assessed with a comprehensive neuropsychological battery. This adolescent patient achieved full remission of clinical symptoms after an acute course of 18 MST treatments and had no apparent cognitive decline, other than some autobiographical memory impairment that may or may not be related to the MST treatment. This case report suggests that MST may be a safe and well tolerated intervention for adolescents with treatment-resistant bipolar depression. Pilot studies to further evaluate the effectiveness and safety of MST in adolescents warrant consideration.

Depressive symptoms and its associated factors in 13-year-old urban adolescents

The available estimates reveal that 20-50% of adolescents report depressive symptoms, being one of the most prevalent health problems in adolescence. The aim of this study was to assess the prevalence of depressive symptoms in a community sample of 13-year-old adolescents and identify associated features. Thirteen year-old adolescents attending private and public schools in Porto (n = 1,988, 52.2% females) were evaluated from October 2003 to June 2004 and completed a questionnaire including health behaviors and the Beck Depression Inventory II. A questionnaire on parents' socio-demographics and clinical characteristics was sent home. Data were analyzed separately by sex. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression. The prevalence of depressive symptoms was 18.8% in girls and 7.6% in boys (p < 0.001). Boys with a family history of depression and girls with smoking habits had a significantly increased risk of depressive symptoms (OR = 2.18, 95%CI 1.00-4.71; OR = 2.34, 95%CI 1.46-3.76). Menarche at an early age significantly increased the risk of depressive symptoms. The characteristics most strongly associated with depressive symptoms were family history of depression among boys, tobacco consumption and an early age at menarche among girls. The high prevalence of depressive symptoms early in adolescence calls for the awareness of public health professionals.

The COPE healthy lifestyles TEEN randomized controlled trial with culturally diverse high school adolescents: baseline characteristics and methods

Obesity and mental health disorders remain significant public health problems in adolescents. Substantial health disparities exist with minority youth experiencing higher rates of these problems. Schools are an outstanding venue to provide teens with skills needed to improve their physical and mental health, and academic performance. In this paper, the authors describe the design, intervention, methods and baseline data for a randomized controlled trial with 779 culturally diverse high-school adolescents in the southwest United States. Aims for this prevention study include testing the efficacy of the COPE TEEN program versus an attention control program on the adolescents' healthy lifestyle behaviors, Body Mass Index (BMI) and BMI%, mental health, social skills and academic performance immediately following the intervention programs, and at six and 12 months post interventions. Baseline findings indicate that greater than 40% of the sample is either overweight (n = 148, 19.00%) or obese (n = 182, 23.36%). The predominant ethnicity represented is Hispanic (n = 526, 67.52%). At baseline, 15.79% (n = 123) of the students had above average scores on the Beck Youth Inventory Depression subscale indicating mildly (n = 52, 6.68%), moderately (n = 47, 6.03%), or extremely (n = 24, 3.08%) elevated scores (see Table 1). Anxiety scores were slightly higher with 21.56% (n = 168) reporting responses suggesting mildly (n = 81, 10.40%), moderately (n = 58, 7.45%) or extremely (n = 29, 3.72%) elevated scores. If the efficacy of the COPE TEEN program is supported, it will offer schools a curriculum that can be easily incorporated into high school health courses to improve adolescent healthy lifestyle behaviors, psychosocial outcomes and academic performance.

Development and process evaluation of a primary care internet-based intervention to prevent depression in emerging adults

BACKGROUND

Primary care is a potential setting for implementation of depression prevention interventions using cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). The purpose of this study was to develop and conduct a process evaluation of a primary care/ Internet-based intervention that addresses key dissemination barriers in a community setting.

METHOD

We used an interdisciplinary team of investigators in a multistep intervention development process among a sample of primary care patients (aged 18 to 24 years). The intervention included an initial primary care motivational interview to engage the participant, 11 Internet-based modules based on CBT (to counter pessimistic thinking) and IPT (to activate social networks and strengthen relationship skills), and a follow-up motivational interview in primary care to enhance behavior change. Each component of the intervention was rated with regard to dissemination barriers of (1) fidelity, (2) motivation, (3) dose, (4) perceived helpfulness (rated on a Likert scale), and (5) potential costs. The study was conducted from April through June of 2004.

RESULTS

Fidelity checklist and serial reviews were satisfactory (100% core concepts translated into intervention). Key motivations for participation included (1) risk reduction, (2) intervention effectiveness, (3) "resiliency," and (4) altruism. In terms of dose, 13 of 14 participants engaged the Internet-based components, completing a mean of 7.2 modules (SD = 3.9). The 2 primary care interviews and the self-assessment and resiliency modules received the highest helpfulness ratings. The duration of the 2 motivational interviews was approximately 17-18 minutes, which is similar to a typical primary care visit.

CONCLUSIONS

By using multidisciplinary teams and incorporating the opinions of potential users, complex preventive mental health interventions can be translated into primary care settings with adequate fidelity, motivation, dose, and perceived helpfulness, and at a reasonably low cost.

Strengthening PNP curricula in mental/behavioral health and evidence-based practice

INTRODUCTION

The incidence of mental health/behavioral and developmental problems in children and teens is escalating. However, many primary care providers report inadequate skills to accurately screen, identify, and manage these problems using an evidence-based approach to care. Additionally, educational programs that prepare pediatric nurse practitioners (PNPs) have been slow to incorporate this content into their curriculums.

METHODS

The purpose of this project was to implement and evaluate a strengthened curriculum in 20 PNP programs from across the United States that focused on: (a) health promotion strategies for optimal mental/behavioral health and developmental outcomes in children, and (b) screening and evidence-based interventions for these problems. An outcomes evaluation was conducted with faculty and graduating students from the participating programs along with faculty and students from 13 PNP programs who did not participate in the project.

RESULTS

Participating schools varied in the speed at which components of the strengthened curriculum were incorporated into their programs. Over the course of the project, faculty from participating programs increased their own knowledge in the targeted areas and reported that their students were better prepared to assess and manage these problems using an evidence-based approach. Although reports of screening for certain problems were higher in the graduating students from the participating schools than the non-participating schools, the overall use of screening tools by students in clinical practice was low.

DISCUSSION

There is a need for educational programs to strengthen their curricula and clinical experiences to prepare students to screen for, accurately identify, prevent, and provide early evidence-based interventions for children and teens with mental health/behavioral and developmental problems. This project can serve as a national model for curriculum change.

Randomized clinical trial of an Internet-based depression prevention program for adolescents (Project CATCH-IT) in primary care: 12-week outcomes

OBJECTIVE

The authors sought to evaluate 2 approaches with varying time and complexity in engaging adolescents with an Internet-based preventive intervention for depression in primary care. The authors conducted a randomized controlled trial comparing primary care physician motivational interview (MI, 5-10 minutes) + Internet program versus brief advice (BA, 1-2 minutes) + Internet program.

SETTING

Adolescent primary care patients in the United States, aged 14 to 21 years.

PARTICIPANTS

Eighty-four individuals (40% non-white) at increased risk for depressive disorders (subthreshold depressed mood >3-4 weeks) were randomly assigned to either the MI group (n = 43) or the BA group (n = 40).

MAIN OUTCOME MEASURES

Patient Health Questionnaire-Adolescent and Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

Both groups substantially engaged the Internet site (MI, 90.7% vs BA 77.5%). For both groups, CES-D-10 scores declined (MI, 24.0 to 17.0, p < .001; BA, 25.2 to 15.5, p < .001). The percentage of those with clinically significant depression symptoms based on CES-D-10 scores declined in both groups from baseline to 12 weeks, (MI, 52% to 12%, p < .001; BA, 50% to 15%, p < .001). The MI group demonstrated declines in self-harm thoughts and hopelessness and was significantly less likely than the BA group to experience a depressive episode (4.65% vs 22.5%, p = .023) or to report hopelessness (MI group of 2% vs 15% for the BA group, p = .044) by 12 weeks.

CONCLUSIONS

An Internet-based prevention program in primary care is associated with declines in depressed mood and the likelihood of having clinical depression symptom levels in both groups. Motivational interviewing in combination with an Internet behavior change program may reduce the likelihood of experiencing a depressive episode and hopelessness.

Development and clinical use of Rapid Assessment for Adolescent Preventive Services (RAAPS) questionnaire in school-based health centers

INTRODUCTION

The purpose of this study is to describe the development and clinical use of Rapid Assessment for Adolescent Preventive Services (RAAPS), a time-efficient screening tool to assess for multiple adolescent risk behaviors.

METHOD

A retrospective chart audit was conducted to obtain descriptive data of middle school (N = 106) and alternative high school (N = 39) adolescents who completed the 17- to 18-item RAAPS questionnaire. Surveys assessed providers' evaluations of the RAAPS.

RESULTS

Descriptive statistics and qualitative analysis indicated that providers using the RAAPS were able to identify risk behaviors/factors, provide counseling for these behaviors, and refer 26% of 9- to 15-year-olds and 43% of 16- to 20-year-olds for further assessment or ongoing risk counseling. In one brief clinic visit, the providers were able to address and document most risk behaviors/factors reported by the adolescents.

DISCUSSION

Although psychometric analysis is needed, the RAAPS is a time efficient and comprehensive risk assessment tool. Early risk identification can assist providers in tailoring specific preventative education counseling and intervention programs that are geared to meet the specific needs of the adolescent population.

Predicting future risk of depressive episode in adolescents: the Chicago Adolescent Depression Risk Assessment (CADRA)

PURPOSE

A risk prediction index, similar to those used for other disorders, such as cardiovascular disease, would facilitate depression prevention by identifying those who would benefit most from preventative measures in primary care settings.

METHODS

The National Longitudinal Study of Adolescent Health enrolled a representative sample of US adolescents and included a baseline survey in 1995 and a 1-year follow-up survey in 1996 (n = 4,791). We used baseline risk factors (social and cognitive vulnerability and mood) to predict onset of a depressive episode at 1-year follow-up (eg, future risk of episode) and used boosted classification and regression trees to develop a prediction index, The Chicago Adolescent Depression Risk Assessment, suitable for a personal computer or hand-held device. True and false positives and negatives were determined based on concordance and discordance, respectively, between the prediction-category-based index and actual classification-category-based 1-year follow-up outcome. We evaluated the performance of the index for the entire sample and with several depressive episode outcomes using the standard Center for Epidemiologic Studies Depression (CES-D) scale cutoffs.

RESULTS

The optimal prediction model (including depressed mood and social vulnerability) was a 20-item model with an area under the receiver operating characteristics curve of 0.80 (95% CI, 0.714-0.870), a sensitivity of 75%, and a specificity of 76.5%. For depressive episode, the positive predictive values in the highest risk group (level 4) was from 13.75% for a depressive episode to 63.57% for CES-D score of greater than 16 (mild to moderate depressed mood or above) at follow-up. Conversely, the negative predictive value of being in the lowest 2 levels (0 or 1) was 99.38% for a depressive episode and 89.19% for a CES-D score of greater than 16.

CONCLUSIONS

Our model predicts a depressive episode and other depressive outcomes at 1-year follow-up. Positive and negative predictive values could enable primary care physicians and families to intervene on adolescents at highest risk.

Depression in children and adolescents

Primary care physicians are often the first health care providers to have contact with depressed children and adolescents. This article discusses the epidemiology, clinical features, comorbid conditions, risk and protective factors, treatment modalities, and clinical course of early-onset depression.

The impact of prescribed psychotropics on youth

Many psychotropics prescribed to children are unlicensed or off-label. This article uses the two most prescribed psychotropics (MPH and SSRIs) to illustrate various concerns about their impact on youth. Many mental illnesses begin in childhood or early adulthood, warranting a treatment of some kind. However, commentators have argued that prescribing is influenced by five myths: (1) children are little adults; (2) children have no reason to develop depression or anxiety; (3) psychiatric disorders are the same across adults and children; (3) children can be prescribed lower doses of the same drug; (5) drugs are preferable to alternative treatments and are more successful. Several lines of evidence suggest that these are incorrect assumptions. We update readers with recent research in relation to these myths, concluding that researchers should clarify child/adult differences for psychotropics, attend to the growth of "cosmetic" use of psychotropics in children and adolescents, and address concerns about the diagnostic validity of mental illness in the current DSM classification system.

Adolescent depression: challenges and opportunities: a review and current recommendations for clinical practice

Many aspects of the treatment for adolescent depression are still uncertain. However, our body of knowledge continues to accumulate, and our approaches continue to be refined. When we remember that 40 years ago the field was still arguing about the existence of depression in youth, it is clear that significant progress has been made. Recent controversies have provided another opportunity to step back and re-evaluate. Given the chronicity, morbidity, and mortality associated with adolescent depression, the risks of doing nothing are too great. Evidence-based research has provided us with some direction during this unsettling time. After careful reviews, the major professional organizations representing pediatric medicine and psychiatry all support the continued use of SSRI antidepressant medications but emphasize close monitoring. The debates also have heightened interest in effective psychotherapy approaches, particularly CBT and IPT. Given the risk for suicidality in depressed adolescents, assessment and management of safety concerns remain critical, regardless of medication usage. Above all, it is most important that we remain hopeful about our ability to guide adolescents and families through the struggles with depression toward recovery.