Pediatric depressive disorders: management priorities in primary care.

PURPOSE OF REVIEW: Depression is a common disorder that affects many youth. Although these youth are often managed in primary care, there is very little research or clinical guidance for primary care professionals to identify and manage depression in their pediatric patients. This review will examine the current evidence for the identification and management of pediatric depression in primary care. RECENT FINDINGS: Several recent primary studies and knowledge syntheses support the identification and management of adolescent depression in primary care with less evidence addressing depression in prepubertal patients. Research evidence from specialty care confirms the efficacy of antidepressants and psychotherapies in adolescent depression. However, there is the possible risk of rare but serious adverse events, as outlined in the Food and Drug Administration's warning, when using antidepressants to treat these youth. SUMMARY: Pediatric depression is often managed by primary care professionals. Several recent studies and reviews have been conducted to provide clinical guidance for the identification and management of depression in primary care.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management.

OBJECTIVES: To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings. METHODS: By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience. RESULTS: Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan. CONCLUSIONS: This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management.

OBJECTIVES: To update clinical practice guidelines to assist primary care (PC) in the screening and assessment of depression. In this second part of the updated guidelines, we address treatment and ongoing management of adolescent depression in the PC setting. METHODS: By using a combination of evidence- and consensus-based methodologies, the guidelines were updated in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) revision and iteration among the steering committee, including youth and families with lived experience. RESULTS: These updated guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in PC, including (1) active monitoring of mildly depressed youth, (2) treatment with evidence-based medication and psychotherapeutic approaches in cases of moderate and/or severe depression, (3) close monitoring of side effects, (4) consultation and comanagement of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and the grade of its evidence base are summarized. CONCLUSIONS: The Guidelines for Adolescent Depression in Primary Care cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist PC clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of depressed youth in PC is needed, including the usability, feasibility, and sustainability of guidelines, and determination of the extent to which the guidelines actually improve outcomes of depressed youth.

Improving recognition of adolescent depression in primary care.

OBJECTIVE: To address the following questions: (1) What evidence (ie, psychometric data collected in pediatric primary care, patient outcome data) exists for the various methods used to identify adolescent depression in primary care? and (2) What identification practices are currently in use? DATA SOURCES: We systematically searched MEDLINE for English-language articles using specific search terms and examined relevant titles, abstracts, and articles. STUDY SELECTION: We reviewed 1743 MEDLINE abstracts. Seventy-four articles were pulled for examination, with 30 articles meeting full criteria. DATA EXTRACTION: Five studies had adequate psychometric data on various adolescent depression identification methods in primary care. Only 1 compared the diagnostic accuracy of physicians trained to ask depression questions vs physicians trained in the use of a diagnostic aid. Six studies reported on current practice. Evidence regarding sensitivity, specificity, positive predictive value, and negative predictive value was sought for question 1. Frequency of screening was sought for question 2. DATA SYNTHESIS: Review of these articles found that few health care professionals use systematic depression identification methods, despite some growing evidence for their validity, feasibility, and possible efficacy. CONCLUSION: Available evidence indicates that primary care professionals would improve their rates of depression diagnosis through training, but even more so by using adolescent symptom rating scales.

Screening for depression in urban Latino adolescents.

PURPOSE: Investigations were conducted on whether screening for adolescent depression was feasible and acceptable to patients in low-income, urban, predominantly Latino clinics. Further investigations were undertaken for provider acceptance of such screening. METHODS: Adolescents aged between 13 and 20 years presenting to 3 pediatric and adolescent primary care practices affiliated with an academic medical center in New York City were screened for depressive symptoms using the Columbia Depression Scale. Providers were surveyed pre- and postimplementation of the screening regarding their attitudes and practices. RESULTS: The vast majority (92%) of those approached accepted the screening. Twelve percent of those screened were referred for mental health treatment. Providers reported satisfaction with the screening tool and a desire to continue to use it. Screening was limited to 24% of eligible participants, and only 10% of screens were at sick visits. CONCLUSIONS: The Columbia Depression Scale seems acceptable to adolescent providers and patients in the mostly Latino study population. It may prove to be a helpful tool in evaluating adolescents presenting to primary care for depression. Further study will be required in other Spanish-speaking and minority populations. New methods will also be required to reach a greater proportion of patients, particularly those presenting for sick visits.

Reported physician skills in the management of children's mental health problems following an educational intervention.

OBJECTIVE: The tristate Reaching Children Initiative (RCI) was designed to engage primary care physicians (PCPs) and increase reported knowledge and skills in the diagnosis and management of the most common mental health (MH) problems among children and adolescents. METHODS: PCPs responded to a baseline survey and agreed to participate in an educational intervention or serve in a comparison group. The program, delivered by an interdisciplinary faculty, engaged the audience in role play, motivational techniques, and didactics. To assess the overall effectiveness of the intervention, baseline, and 6-month follow-up, surveys asked PCPs to rate their knowledge, diagnostic skills regarding socioemotional problems, knowledge of treatment strategies for these problems, awareness of MH resources, and attitudes towards diagnosing and treating MH problems. RESULTS: Of the 215 baseline respondents, 137 chose to participate in the educational intervention and 78 served as a comparison group; of these, 64% and 59%, respectively, completed the 6-month survey. The overall sample was predominantly female (70.2%), white (64.7%), and had been in practice for over 10 years (57.5%). Repeated measures analysis, confirmed by propensity analyses, revealed significantly improved reported mean scores for diagnostic skills and knowledge of clinical strategies for the intervention relative to the comparison group. The intervention did not significantly impact awareness of resources or attitudes. CONCLUSIONS: Following the RCI, PCPs did report significant changes in self-efficacy specific to diagnostic skills and knowledge of clinical treatment strategies for targeted MH content. This educational approach merits further study.

Expert survey for the management of adolescent depression in primary care.

OBJECTIVE: Primary care clinics have become the "de facto" mental health clinics for teens with mental health problems such as depression; however, there is little guidance for primary care professionals who are faced with treating this population. This study surveyed experts on key management issues regarding adolescent depression in primary care where empirical literature was scant or absent. METHODS: Participants included experts from family medicine, pediatrics, nursing, psychology, and child psychiatry, identified through nonprobability sampling. The expert survey was developed on the basis of information from focus groups with patients, families, and professionals and from the research literature and included sections on early identification, assessment and diagnosis, initial management, treatment, and ongoing management. Means, standard deviations, and confidence intervals were calculated for each survey item. RESULTS: Seventy-eight of 81 experts agreed to participate (return rate of 96%). Fifty-three percent of the experts (n = 40) were primary care professionals. Experts endorsed routine surveillance for youth at high risk for depression, as well as the use of standardized measures as diagnostic aids. For treatment, "active monitoring" was deemed appropriate in mild depression with recent onset. Medication and psychotherapy were considered acceptable options for treatment of moderate depression without complicating factors such as comorbid illness. Fluoxetine was rated as the most appropriate antidepressant for use in this population. Finally, experts agreed that patients who are started on antidepressants should be followed within 2 weeks after initiation. CONCLUSIONS: Survey results support the identification and management of adolescent depression in the primary care setting and, in specific situations, referral and co-management with specialty mental health professionals. Even with the recent controversies around treatment, experts across primary care and specialty mental health alike agreed that active monitoring, pharmacotherapy with selective serotonin reuptake inhibitors, and psychotherapy can be appropriate under certain clinical circumstances when initiated within primary care settings.

Adolescent depression screening in primary care: feasibility and acceptability.

OBJECTIVE: Despite available depression treatments, only one fourth to one third of depressed adolescents are receiving care. The problem of underdiagnosis and underreferral might be redressed if assessment of suicidality and depression became a more formal part of routine pediatric care. Our purpose for this study was to explore the feasibility and acceptability of implementing adolescent depression screening into clinical practice. METHODS: In this study we implemented a 2-stage adolescent identification protocol, a first-stage pen-and-paper screen and a second-stage computerized assessment, into a busy primary care pediatric practice. Providers tracked the number of eligible patients screened at both health maintenance and urgent care visits and provided survey responses regarding the burden that screening placed on the practice and the effect on patient/parent-provider relationships. RESULTS: Seventy-nine percent of adolescent patients presenting for health maintenance visits were screened, as were the majority of patients presenting for any type of visit. The average completion time for the paper screen was 4.6 minutes. Providers perceived parents and patients as expressing more satisfaction than dissatisfaction with the screening procedures and that the increased time burden could be handled. All providers wished to continue using the paper screen at the conclusion of the protocol. CONCLUSIONS: Instituting universal systematic depression screening in a practice with a standardized screening instrument met with little resistance by patients and parents and was well perceived and accepted by providers.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management.

OBJECTIVES: To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This first part of the guidelines addresses identification, assessment, and initial management of adolescent depression in primary care settings. METHODS: By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 5 phases, as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) draft revision and iteration among members of the steering committee. RESULTS: Guidelines were developed for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in primary care, including identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The identification, assessment, and initial management section of the guidelines includes recommendations for (1) identification of depression in youth at high risk, (2) systematic assessment procedures using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, (3) patient and family psychoeducation, (4) establishing relevant links in the community, and (5) the establishment of a safety plan. CONCLUSIONS: This part of the guidelines is intended to assist primary care clinicians in the identification and initial management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists but cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for adolescent depression management. Additional research that addresses the identification and initial management of depressed youth in primary care is needed, including empirical testing of these guidelines.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management.

OBJECTIVES: To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This second part of the guidelines addresses treatment and ongoing management of adolescent depression in the primary care setting. METHODS: Using a combination of evidence- and consensus-based methodologies, guidelines were developed in 5 phases as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) revision and iteration among members of the steering committee. RESULTS: These guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in primary care, including (1) active monitoring of mildly depressed youth, (2) details for the specific application of evidence-based medication and psychotherapeutic approaches in cases of moderate-to-severe depression, (3) careful monitoring of adverse effects, (4) consultation and coordination of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and its evidence base are summarized. CONCLUSIONS: These guidelines cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist primary care clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of youth with depression in primary care is needed, including the usability, feasibility, and sustainability of guidelines and determination of the extent to which the guidelines actually improve outcomes of youth with depression.