Peds depression

Question 1

How many adolescents with depression are dx b/f they reach adulthood? How many get adequate tx?

Answer 1

• only 50% with depression are dx b/f they reach adulthood

- only 50% of those dx get adequate tx

Question 2

Prevalence of depression in peds?

Answer 2

• pre-puberty: 1-2%, girls:boys 1:1

- post-puberty: 3-8%, girls:boys 2:1

Question 3

RFs for depression?

Answer 3

• personal or family hx of depression
• personal or family hx of bipolar disorder
• suicide related behavior
• substance abuse
• other psychiatric illnesses
• significant psychosocial stressors (family crisis, abuse, neglect, trauma)

Question 4

Screening tools used for depression?

Answer 4

• screen if sxs warrant it and do this yearly
• GAPS (guidelines for adolescent preventive services)
• beck depression inventory
• kutcher adolescent depression scale
• SDQ (strengths and difficulties questionnaire)
• personal interview: HEADSS

Question 5

What does HEADSS stand for?

Answer 5

• H (home)
• E (education, employment)
• A (activities)
• D (drugs)
• S (sexuality)
• S (suicide/depression)

Question 6

Criteria for dx of depression (DSM IV-TR and DSM 5)?

Answer 6

• major depressive episode in kids and adolescents typically includes at least 5 of the following sxs during the same 2 wk period
• at least one of the sxs needs to be depressed mood or loss of interest or pleasure

Major depressive episode criteria:

• depressed or irritable mood
• diminished interest or loss of pleasure in almost all activities
• sleep disturbance (sleeping all the time, insomnia)
• wt change, appetite disturbance, or failure to achieve expected wt gain
• decreased concentration or indecisiveness
• suicidal ideation or thoughts of death
• psychomotor agitation or retardation
• fatigue or loss of energy
• feelings of worthlessness or inappropriate guilt
• sxs are not due to medical condition or other psychiatric disorder (bipolar- want to rule this out first!)
• sxs are not due to direct physiological effects of a substance
• sxs are not better accounted for by bereavement beyond 2 months

Question 7

Depressive sxs in kids and pre-pubertal youth?

Answer 7

• somatic complaints: HA, belly pain, nausea
• psychomotor agitation
• mood-congruent hallucinations
• school refusal
• phobias/separation anxiety/increase in worrying

Question 8

Typical sxs of a pre-pubertal child with depression?

Answer 8

• child used to enjoy hanging out with friends now continually complaining of HAs or abdominal pain to get out of school. Withdrawal from sports and extracuricular activities. Expresses constant worry over activities at recess and is biting his fingernails until they bleed, he wants nothing to do with his friends.

Question 9

Depression sxs in adolescents and post-pubertal youth?

Answer 9

• low self esteem, apathy, boredom
• substance abuse
• change in wt, sleep or grades
• psychomotor depression/hypersomnia
• aggression/antisocial behavior
• social withdrawal

Question 10

Typical sxs of an adolescent with depression?

Answer 10

• 16 yo female - who was previously a good student, now is skipping school and getting into fights. She is barely passing her classes and has been caught shoplifting 2x. She has also started smoking pot, changed friends and showers only 2-3x a week. Stays locked in her room and won’t join family for meals

Question 11

Diff in sxs in younger kids and teens?

Answer 11

• younger kids: may present more somatic sxs and more likely to have psychomotor agititation
• teens may be more likely to present with social withdrawal, substance use and psychomotor depression

Question 12

Signs and sxs of major depression? SIGECAPS

Answer 12

S: sleep disturbance
I: interests (decreased)
G: guilt (excessive or inapprop.)
E: energy (decreased)
C: concentration probs
A: appetite change
P: pleasure (decreased)
S: suicidal thoughts or actions

Question 13

Interviewing the child and parent?

Answer 13

• screening forms specifically for the parents/caregivers to fill out
• directed interview
• remember to maintain confidentiality b/t the parents and the pt
• goal is to est. how much support the pt has and to assess for safety (suicidal behaviors)

Question 14

What other etiologies should you rule out b/f dx depression?

Answer 14

• infection: mono
• med side effects
• endocrine disorder: thyroid disorder
• tumot
• neuro disorder
• miscellaneous: anemia

Question 15

DDx of depression?

Answer 15

• normal moodiness of teens
• major depressive disorder
• substance induced mood disorder
• adjustment disorder
• anxiety disorder
• PTSD
• bipolar disorder
• eating disorder
• conduct disorder

Question 16

How common is suicide in adolescents?

Answer 16

• 3rd leading COD
• risk of suicide may increase at the pt recovers some from depression and has more energy and motivation
• in 2014 - q 12.2 min someone in US died from suicide

Question 17

Most common suicide methods?

Answer 17

• firearms: 51%
• suffocationL 25%
• poisoning: 17%
• other: 8%

Question 18

Suicide stats - men vs women?

Answer 18

• white males are 4x more likely than females to die by suicide
• females attempt suicide 3x as often as males (poisoning, and OD on drugs)
• ratio of suicide attempts to suicide death in youth is est to be about 25:1, compared to about 4:1 in elderly

Question 19

Suicidal behaviors in kids and teens?

Answer 19

• expressing self destructive thoughts
• drawing morbid or death related pictures
• using death as a theme during paly in young kids
• listening to music that centers around death
• playing video games that have a self-destructive theme
• reading books or other publications that focus on death
• watching tv shows that center around death
• visiting internet sites that contain death related content
• giving away possessions

Question 20

What teens are at high risk for suicide? (SAD PERSONS)

Answer 20

• family hx of first degree relative who committed suicide*
• S (sex): females attempt more, males* complete more
• A (age): over 16*
• D (depression) and comborbid conduct disorder/impulsive/aggression/anxiety
• P (previous attempts)*
• E (ETOH) or other substance abuse (SA)
• R (rational thinking lost) psychotic or SA
• S (social supports lacking)*
• O (organized plan) **
• N (no significant other)
• S (sickness or stressors)

Question 21

Tx for depression?

Answer 21

1. initial management of depression included pt and caregiver education
2. develop a tx plan with pt and family
3. est relevant links with mental health resources in community
4. safety plan

Question 22

Step 1: initial management?

Answer 22

• educate that depression is often recurrent and what tx options are available
• parental rxn may include sadness, anger or denial
• confidentially - make it clear that content of the visits are confidential unless there is evidence of imminent harm to self or others

Question 23

Step 2: develop tx plan?

Answer 23

• set specific tx goals in key areas of fxning:
  home, peer, and school settings
  written goals (HW, exercise, self care)
• determine tx plan based on severity of sxs:
  CBT, interpersonal psychotherapy, SSRIs

Question 24

Step 3: community resources?

Answer 24

• refer to approp. support groups which may be available in the community

Question 25

Step 4: safety plan?

Answer 25

- all management must include a safety plan - this is a specific set of instructions for the pt to help recognize their sxs and what they will do if they feel unsafe

Question 26

Tx options for depression in peds?

Answer 26

- CBT - interpersonal psychotherapy - SSRIs

Question 27

Tx for mild depressive sxs?

Answer 27

- may choose active monitoring for short time - frequent visits - Rx regular exercise or leisure activities - recommend peer support group - review self management goals - provide education

Question 28

CBT tx?

Answer 28

- based on principle that one's thoughts, feelings and behaviors affect one another - goal of tx: modify the negative thoughts and behaviors

Question 29

Interpersonal psychotherapy?

Answer 29

- based on principle that depression occurs in an interpersonal context - goal of tx: address the interpersonal problems that may be contributing to or resulting from the depression

Question 30

1st steps of pharmacotherapy?

Answer 30

start by: -assessing prior tx success - family hx of successful antidepresant use ("zoloft worked great for my mom") - discussion of duration of tx (6 mo to 1 yr after cessation of sxs- don't want to take off too soon - relapse of sxs) - reviewing safety data of meds: take for 4-6 wks for SSRI response - review side effects

Question 31

Medical tx with SSRIs?

Answer 31

- fluoxetine (prozac): FDA approved ages 8 and up for depression and OCD - escitalopram (lexapro): FDA approved ages 12 and up for depression

Question 32

Use of prozac, pros?

Answer 32

- recommended 1st line SSRI - 10 mg once daily - taper up by 10 mg increments q 1-2 weeks: take 1/2 of 20 mg tab for 2 wks then increase to whole tab - effective dose: 20 mg - max dose: 60 mg - pros: long half life so less withdrawal sxs if missing dosing mult successful med trials in adolescents

Question 33

Use of Escitalopram (lexapro)?

Answer 33

- FDA approved for 12 and older first line - starting dose 5 mg daily - effective dose 10-20 mg - max: 20 mg

Question 34

Rules of SSRI therapy in depression? How long b/f the dosage should be changed?

Answer 34

- don't abruptly stop, SSRIs need to be tapered up and down - don't increase dose any more frequently then 4-6 wk increments - try to wait out mild side effects like HA and GI SEs for week or so to see if they subside - don't stop med for SE just decrease it and see what happens (unless severe)

Question 35

Common SSRI side effects?

Answer 35

- HA - GI upset - insomnia - agitation - anxiety

Question 36

Other SEs of SSRIs that aren't as common?

Answer 36

- dry mouth - constipation - sweating - sexual dysfxn - irritability - disinhibition - appetite changes (generally eat more, wt gain) - rash - serotonin syndrome - akathisia: agitation, feeling restless - hypomania - d/c syndrome

Question 37

BBW for SSRIs?

Answer 37

- increased suicidality risk in kids, adolescents, and young adults with major depressive or other psychiatric disorders - weigh risk vs benefit, in short term studies of antidepressants vs placebo - suicidality risk not increased in pts older than 24, and risk is decreased in pts older than 65

Question 38

BBW - actual suicide attempts or thoughts?

Answer 38

- 24 clinical trials/4400 kids and adolescents on antidepressants - no suicides in these trials - those taking meds were more likely to spontaneously report suicidal thoughts or behaviors 2/100 not on meds vs 4/100 on meds

Question 39

F/U for pts with depression?

Answer 39

- f/u with these pts q week to 2 weeks at first - once a maintenance dose f/u once a month for several months then move to quarterly - continually assess suicidality - CBT or IPT plus meds have better response to tx - track written goals - give all instructions in writing and document pt and parent education - if no improvement in sxs after 4-6 wks of optimum dosing refer for mental health consultation - use screening tools to assess response to tx - involve pt and family

Question 40

When should you refer pt on to psychiatrist?

Answer 40

- if suspect comorbid psych disorders or bipolar disorder - refer on - complex managment - if pt not improving after 4-6 wks