The Snohomish County Child Health Notes - November, 2019

Promoting partnerships between primary health care providers, families, and the community to support early identification
of children and youth with special needs and comprehensive care within a primary care medical home.

Distributed by: Snohomish Health District
Contributors: University of Washington, Center on Human Development & Disability (CHDD) & the Washington State Department of Health (DOH).
Issue author: Sophie Lu, MN, ARNP, Developmental Pediatric Nurse Practitioner, UW CHDD. Reviewers: Ellen Silverman, RN, PhD, Nurse Consultant, DOH; Lacey Coffin-Greene, Program Manager, Washington Chapter of the American Academy of Pediatrics (WCAAP)

Adolescent Depression: Screening and Management in Primary Care

Depression Management in Adolescents

Studies have indicated that only 50% of adolescents with depression are diagnosed before reaching adulthood. i Research has also revealed that up to 9% of teenagers meet criteria for depression at any one time, and in primary care (PC) settings prevalence rates are likely higher (up to 28%). ii In 2016, an estimated 3.1 million or 12.8% of adolescents aged 12 to 17 years in the United States had at least one major depressive episode with an estimated 2.2 million of this population having at least one major depressive episode with severe impairment. Of adolescents with major depressive episode, approximately 70% had severe impairment, or 9% of the U.S. population aged 12 to 17. The prevalence of major depressive episode was higher among adolescent females (19.4%) compared to males (6.4%), and was highest among adolescents reporting two or more races (13.8%). iii

The American Academy of Pediatrics (AAP) recently published updated guidelines for depression in youth aged 10 to 21 years. These guidelines address the screening, identification, assessment, diagnosis, treatment and ongoing management of depression in PC.

Risk factors for depression may be biological (i.e. family history of depression, chronic medical illness, obesity), psychological (i.e. history of suicide attempts, ineffective coping skills, low self-esteem, negative body image) or environmental (i.e. poor peer relationships, decreased physical activity, increased parental conflict, poor academic performance, low socioeconomic status, substance use). Common symptoms of depressive disorders are:

sad or irritable mood, decreased interest or lack of enjoyment, decreased concentration or indecision, feelings of worthlessness or excessive guilt, feelings of hopelessness, insomnia or hypersomnia, change of appetite or change of weight, fatigue, recurrent thoughts of death or suicidal ideation

Focus: Two Validated Mental Health Screening Instruments

Pediatric Symptom Checklist -Youth  Report  (PSC - Youth) •	Age 11 years and older •	35 items, self-report •	General Mental Health screening and functional screening, including attention, externalizing, internalizing symptoms  •	Time to administer: 5 minutes, scoring 1-2 minutes. •	Minimum expertise: No special qualifications for admin/scoring. •	Reliability: test-retest 0.45. Validity: “strong” concurrent validity. Sensitivity: .94. Specificity: .88	Patient Health Questionnaire, Modified for Teens (PHQ-9, Modified) •	Ages 12-18 •	9 items, self-report •	Screen for depression & suicide risk. Wording slightly modified from PHQ-9. •	Time to administer: <5 minutes •	Minimum expertise: professional or office staff •	Reliability: No data found. Validity: No data found. Sensitivity: .73. Specificity: .94.

Structured depression screening is required by WA Medicaid for children age 12 years and older. Use procedure code 96127.

Initial Management of Depression Recommendations from Seattle Children’s Partnership Access Line (PAL) Primary Care Principles for Child Mental Health iv

Mild Depression (noticeable, but basically functioning OK) Educate patient and family:  ?	Support increased peer interactions ?	Behavior activation, exercise ?	Encourage good sleep hygiene ?	Reduce stressors, if possible ?	Remove any guns from home ?	Offer parent/child further reading resources	Follow up: ?	Follow up appointment in 2-4 weeks to check if situation is getting worse ?	Repeating rating scales helps comparisons ?	Those not improving on their own are referral candidates for counseling Moderate/Severe Depression (significant impairment in one setting, or moderate impairment in multiple settings) Recommend individual psychotherapy: ?	Cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) are preferred, where available ?	Psychoeducation, coping skills, and problem solving focus are all helpful therapy strategies ?	Educate patient and family (as per mild problem list on left) ?	Consider family therapy referral	Consider starting SSRI, especially if severe: ?	Fluoxetine is the first line choice ?	Escitalopram/Sertraline second line ?	Third line agents are other SSRIs, bupropion, mirtazapine ?	Wait four weeks between dose increases to see changes ?	Check for side effects every 1-2 weeks in first month of use to ensure no new irritability or suicidality (phone or in person) ?	Stop SSRI if get agitation, anxiety or suicidal thoughts ?	Consult MH specialist if monotherapy is not helping ?	Monitor progress with repeat use of rating scale

[i] Zuckerbrot, R. A., Cheung, A., Jensen, P. S., Stein, R. K., & Laraque, D. (2018). Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics, 141(3), 1-21. doi:10.1542/peds.2017-4081
[ii] Cheung, A. a., Zuckerbrot, R. A., Jensen, P. S., Laraque, D., & Stein, R. K. (2018). Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management. Pediatrics, 141(3), 1-16. doi:10.1542/peds.2017-4082
[iii] National Institute of Mental Health website. Major Depression.
[iv] Hilt, R. (2017). Seattle Children’s Primary Care Principles for Child Mental Health. Version 7.1. 2017-2018.

Special Needs Information and Resources

Care Crisis Line – 24 hour Crisis Intervention
425-258-4357, 1-800-584-3578
Cocoon House Youth Access Line – Call or text for help with shelter and other services

Partnership Access Line (PAL) Care Guides and Resources

WCAAP Adolescent & Maternal Depression Screening (CME)

State Mental Health Crisis Lines DSHS

Teen Self-Help Cognitive Behavior Therapy (CBT) guidance

National Crisis Hotline

National Suicide Prevention Lifeline

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Mayo Clinic: Diagnosis and Treatment of Depression
American Family Physician Treatment Resource

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