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Depression

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Peggy Greco

on 22 October 2017

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Transcript of Depression

Which treatment?
Dosing for Adolescent Depression
A Closer Look at Depression in the iGeneration
Adolescent Depression and Suicide Risk in the iGeneration
Elise Fallucco, M.D. and Peggy Greco, Ph.D.
Utilize Technology
Depression-Related Apps:
Psychological Approaches
Cognitive Behavioral Therapy
What's Up?
Patient Health Questionnaire-9
Modified for Teens
Workbooks
What if first SSRI doesn't work?
Take-Home
(Take-to-Clinic)
Message
Screen for Depression
Case Examples
Severity/Next Steps?
JAMES - 14 yo assigned male
TREY - 16 yo assigned male
17 yo F, PHQ=23, suicidal thoughts, no intent, father with bipolar

16 yo M, PHQ=19, suicidal thoughts, intent and vague plan

15 yo M, PHQ=21, suicidal thoughts, no intent or plan

goes by Trey, pronouns are he/his
irritable, can't fall asleep
PHQ = 19, Weight = 150 pounds





Initial Treatment Plan
Start Sertraline 25 50 mg qhs

(What should the target dose be?)
Refer for CBT
Offer workbooks and apps

When should you follow-up?


Self-Management Approaches
AACAP Facts for Families
www.aacap.org

Nemours KidsHealth
www.Kidshealth.org
Resources for Families
Web-Based Education
Depression and Suicide
in US teens
Screen and Interview
ABCs of CBT
What should you convey to parents and kids about CBT?
CBT refers to cognitive-behavioral therapy, a category of treatment that is based on the theory that we can change our feelings by changing our thoughts
"Therapy is also very effective at reducing depression, particularly a type of therapy called cognitive-behavioral therapy. Not only will it help decrease depression now, but
your teen will gain tools to help reduce stress and manage moods throughout life.
"
Depression rates climb in past decade (from 2005 to 2014):
8.7% to 11.3%

1 in 6 youth have seriously considered suicide

1 in 12 youth have attempted suicide in past year
Use PHQ-9

3 Step Assessment


Combination Treatment
Workbooks and Apps
Antidepressant Medication
Who Does CBT?
All psychologists
(PhD)
are trained in CBT

May need to determine if other therapists (master's level counselors, social workers, etc. ) have specialized experience in treatment of adolescent depression
QUESTIONS?
Screening

3-Step Assessment

Intervention
-medication
-psychological approaches
-self-help
Everything You Need to Know
About Depression and Suicide in the iGeneration
American Psychological Association

www.APA.org


Anxiety and Depression Association of America
www.adaa.org

National Institute of Mental Health
www.nimh.nih.gov
Referring for CBT
*
*
*
event
THOUGHT
feeling
Stop, Breathe, and Think
Pacifica
Scoring the PHQ9
Total score 11+ possible depression
0 5 10 15 20+
Easily scored at the bottom of the measure
Options to Help with Sleep
sleep hygiene

melatonin 1,2,3

clonidine 0.05-0.1 mg

trazadone 25-50 mg

SSRI + CBT
The Collaborative Care Initiative: A Partnership between Pediatrics and Psychiatry
The Collaborative Care Initiative:
A Partnership between
Pediatrics and Psychiatry

Disclosure: No Conflicts of Interest
CCI Team: Valentina Bolanos MPH, Kitty Leung MD, Lauren James MA
(After titrating to an effective dose: Sertraline 50mg 100mg)

PHQ =10
"Feeling better"

-How long to keep him on this medication?
-How to taper off OR should you stay on med?
-What role should family history/ preference as well as severity play?

PHQ9: Current score = 16 (baseline = 19)
Sleep improving
Started CBT


What treatment options/adjustments do
you make next?



Next Steps: Determine Severity
suicidal intent, mania, psychosis
-> ER (inpatient or PHP)
1st degree relative with

bipolar, psychosis
-
-> consult psychiatrist
depression +/- anxiety
--> therapy, consider meds
* p<0.05 vs. placebo
March et al., JAMA 2004
* CBT + switch to another SSRI



Brent et al., JAMA 2008 (TORDIA)
FREE: http://www.phqscreeners.com
n=439, 12-17 yo MDD
12 week, multisite RCT






smartphones

social media

apps
Two 10-minute interviews: Review PHQ and door note
Do not do a physical exam
iGeneration
New Patient: Jordan's PHQ9
3-Step Interview Process
Step One: Assess Severity
Step Three: Suicide, Safety
Step Two: Rule out
organic
causes or meds
psychosis
"unusual experiences"
bipolar
"don't need to sleep and have plenty of energy?"

1st degree relative with either
Open-ended question:
"Feeling down - can you tell me what's going on?"
How long? Sleep, energy?
HEADS:
H
ome
E
ducation/Employment
A
ctivities/Acquaintances
Drugs
S
ex (romantic relationships)
Plan
: "Do you have a plan for how you might try to end your life?"

Attempt
: "Have you ever tried to end your life?"

Intent
: "Are you focused on ending your life?"

Access to weapons
RED FLAGS!!
Step 3: Suicide

Suicidal thoughts (ST) are common
"When people feel [the way you have described], they sometimes want to..."

- Passive
ST: "fall asleep and not wake up"

- Active
ST: "end their life"
What name do you go by?

What are you preferred pronouns?

Confidentiality
Opening the Interview with the iGeneration
Putting it All Together...
Next Steps: Treat and/or Refer?
suicidal intent, mania, psychosis

ER (inpatient or PHP)
1st degree relative with

bipolar, psychosis

consult psychiatrist
depression +/- anxiety

therapy, consider meds
that meets the needs of the iGeneration...
Transition to Interviews with Standardized Patients
Step 1
: 4 months, affects grades/friends
tried cannabis 2x
Step 2:
ruled out
Step 3:
S. thoughts, no intent or plan
4 Week Follow-up Visit
Titrated up to 30mg
limited improvement


PHQ = low 20s

Switch vs. titrate??


What treatment options do you recommend?
Goes by Jamie, identifies as female, pronouns are "she/her"
Low energy, tired, increased appetite
PHQ9=24, Weight = 105
Step 1: 1 year+, affecting life, no drugs
Step 2: ruled out
Step 3: suicidal thoughts, no intent/plan
What treatment options do you recommend?
8 Week Follow-up Visit
Start Prozac 10 mg qam

(What should the target dose be?)
Refer for CBT
Offer workbooks and apps
Offer LGBT support resources



When should you follow-up?
Initial Treatment Plan
4 Week Follow up Visit
Twenge JM. The Atlantic. Sept 2017
Mojtabai R et al, Pediatrics. Nov 2016;
CDC, YRBSS 2015
Richardson L et al., Pediatrics. 2010.
Placebo
CBT alone
Fluoxetine
Fluoxetine
+CBT
Full transcript