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Collaboration, consultation part of AAP teen depression guidelines update

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Guidelines will boost primary care clinician confidence

“Mental health disorders have become one of the new morbidities in pediatric care,” Karalyn Kinsella, MD, said in an interview. “With one in five patients having depression, it is an illness that must be within our domain to identify and treat. I think the guidelines will make providers feel more confident in making a diagnosis and providing initial treatment. For those that do not feel comfortable, hopefully the guidelines will encourage them to seek training.

Dr. Karalyn Kinsella, a pediatrician in Cheshire, Conn., and a member of the Pediatric News editorial advisory board
Dr. Karalyn Kinsella
“I think many providers may be concerned about the time it takes to identify and treat [depression] as well as a lack of expertise,” she noted. “Ideally, the guidelines will streamline the identification and treatment process to make them more manageable during preventative care visits.”

The take-home message for general pediatricians is that a standardized screening tool makes identifying depression relatively easy. “We have been using the PHQ-9 [Patient Health Questionnaire-9] in my office for several years, and it is very easy to administer and score, and is billable,” said Dr. Kinsella. “It can take some practice to tease out some typical teen behaviors, especially on the sleep and fatigue questions, but it provides an opportunity to open up discussion with the teen.

“Treatment [of depression] can be more complicated and time consuming, but rewarding and invaluable to the patient,” she emphasized. “Many states now have psychiatrists available by phone consultation to aid in management of medication. The key is establishing a list of quality counselors for referrals. With those supports and frequent follow-up, pediatricians can play a key role in the treatment of this prevalent and important illness that affects our patients.”

Dr. Kinsella is a pediatrician in Cheshire, Conn., and a member of the Pediatric News editorial advisory board. She was asked to comment on the new AAP teen depression guidelines.



Primary care providers may be the first to encounter teens with depression; updated guidelines from the American Academy of Pediatrics support their efforts.

The updated information includes recommendations on collaborative care, practice preparation, establishing networks of referrals, and much more.

A doctor taking notes with a young male patient AlexRaths/Thinkstock
“In primary care (PC), as many as two in three youth with depression are not identified by their PC clinicians and fail to receive any kind of care,” wrote Rachel A. Zuckerbrot, MD, of Columbia University Medical Center, New York, and her colleagues.

“These guidelines were developed for PC clinicians who are in a position to identify and assist youth with depression in their practice settings,” they said. The guidelines apply to individuals aged 10-21 years, and support universal depression screening for those aged 12 and older.

Known as the Guidelines for Adolescent Depression in Primary Care (GLAD-PC), they consist of two parts: Practice Preparation, Identification, Assessment, and Initial Management, with Dr. Zuckerbrot as the lead author, and Treatment and Ongoing Management, led by Amy H. Cheung, MD, of the University of Toronto. They were published online in Pediatrics.

“It has been over 10 years since the [last] guidelines were published and they are supposed to be updated every 5,” Dr. Zuckerbrot said in an interview. “Given the new evidence on screening, psychopharmacology, and collaborative care, the guidelines needed to be revised. The USPSTF [United States Preventive Services Task Force ] and the AAP had already supported universal adolescent depression screening, and these guidelines are finally aligned with those positions.

“Different parts of the guidelines will be the go-to for different pediatricians, depending on where they are in their delivery of mental health care,” she explained. “Some may need help with practice preparation while others may need advice on screening; others may already be prescribing and may need advice on ongoing treatment and follow-up. I think there is something for everyone.”

Implementation of the guidelines is difficult in a short visit, Dr. Zuckerbrot acknowledged. “In addition, pediatricians may not have been well trained in the management of adolescent depression during their residencies.” However, the guidelines discuss both “real teams to support the pediatricians in their efforts, as well as virtual teams when staffing is limited.

“The guidelines advise that pediatricians learn about child psychiatry primary care consultation programs in their state and make use of those free telephone consultation programs.” The guidelines also discuss strategies for collaborative or integrative care, she said.

Part I

Part I of the guidelines, “Practice Preparation, Identification, Assessment, and Initial Management,” includes several recommendations for each topic.

For practice preparation, the guidelines recommend that clinicians seek training in the assessment, diagnosis, and treatment of depression, and that they establish a network of referrals and mental health resources in their communities. This network may include not only health professionals, but also current patients and families who are managing teen depression. If available, state-wide or regional child and adolescent psychiatry consultation programs can be included.

The identification and surveillance section of the guidelines calls for screening all patients aged 12 years and older for depression each year, using a formal screening tool on paper or online. The screening could occur at an annual wellness visit or any other medical visit, such as a sports physical. A second recommendation calls for identifying patients at increased risk for depression because of factors such as personal history, family history, substance use, other psychiatric disorders, frequent somatic complaints, or trauma, and monitoring these individuals regularly for signs of depression using a formal screening tool.

The assessment and diagnosis section states that assessment should include interviews with the patients alone as well as with their families or caregivers, and should include screening teens for functional impairment.

Primary care physicians should evaluate for depression not only if an adolescent tests positive on a screening tool, but also in children who present with any emotional problem as the chief complaint, and in those in whom depression is highly suspected even if they test negative on a formal screening tool, the guidelines state.

The three recommendations for initial management of depression in the primary care setting are educating patients and families about depression; developing a treatment plan (if the primary care clinician has had appropriate training) and setting specific treatment goals in areas of functioning such as at home, with peers, and at school; and developing a safety plan that includes restricting access to weapons or other means of self-harm, according to the guidelines.

Part II

Part II of the recommendations, “Treatment and Ongoing Management,” discusses options for managing depression in the primary care setting and utilizing outside resources.

The treatment recommendations emphasize the use of integrated models, if possible. “There is a growing recognition that complex chronic conditions, such as depression, are most successfully managed with proactive, multidisciplinary, patient-centered care teams,” Dr. Cheung and her associates said.

The recommendation for cases of mild depression calls for a period of “active support and monitoring” for 6-8 weeks before reassessing if the teen shows no improvement. By contrast, for cases of moderate to severe depression or cases with evidence of substance abuse or other psychoses, the recommendation calls for potential consultation with a mental health specialist and a discussion of the roles primary and specialty care will play in treatment. The guidelines include a flow chart for PC physicians to follow.

The guidelines suggest that PC clinicians recommend “scientifically tested and proven treatments,” such as psychotherapies, cognitive behavioral therapy (CBT) or interpersonal psychotherapy for adolescents, and/or antidepressant treatment, such as SSRIs, whenever possible and appropriate. It is important to monitor teens on antidepressants regularly to identify adverse events.

Recommendations for the ongoing management of teens with depression in the primary care setting include regular tracking of progress, reassessment if the teen shows no improvement in 6-8 weeks, and consultation with a mental health professional for those who show only partial improvement after exhausting primary care diagnostic and treatment options. Assessment of depressive symptoms is not the only thing to track. Functioning at home, school, and among peers also is important.

The guidelines project was funded by the Resource for Advancing Children’s Health Institute and the Bell Canada Chair in Adolescent Mood and Anxiety Disorders.

Dr. Cheung and Dr. Zuckerbrot receive book royalties. Dr Zuckerbrot works for child and adolescent psychiatry for primary care (CAP-PC), now a regional provider for Project TEACH in New York State, and she is on the steering committee as well as faculty for the REACH Institute; both of these institutions are described in the guidelines. Peter S. Jensen, MD, has received royalties from Random House, Oxford University Press, and APPI Inc. He is a part owner of a consulting company, CATCH Services LLC. He is the chief executive officer and president of a nonprofit organization, the Resource for Advancing Children’s Health Institute, but receives no compensation. The other authors indicated they have no financial relationships relevant to the guidelines.

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