Managing Child and Adolescent Depression: An Expert Interview With Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN

Laurie Barclay, MD

April 28, 2010

April 28, 2010 — Editor's note: Childhood and adolescent depression is often underrecognized and undertreated, according to a study presented at the National Association of Pediatric Nurse Practitioners (NAPNAP) 31st Annual Conference of Pediatric Health Care. The conference, entitled Achieving Vision: Pediatric Health Care Beyond the Millennium, was held in Chicago, Illinois from April 15 to 18.

To learn more about assessment and evidence-based management of children and adolescents with depression by pediatric nurse practitioners, Medscape Nurses interviewed presenter Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, dean and Distinguished Foundation Professor in Nursing at Arizona State University College of Nursing and Health Innovation in Phoenix.

Medscape: How prevalent is childhood and adolescent depression, and what percentage of cases is likely to be undetected?

Dr. Melnyk: Depressive and anxiety disorders among teens, often comorbid conditions, are nationwide public health problems associated with disabling morbidity, significant mortality, and substantial healthcare costs. Untreated depression raises the risk of suicidal behavior and completed suicide, which is the third leading cause of death in adolescents. Recent annual prevalence data from the national surveillance of high school students (9th to 12th graders) indicate that depressive symptoms severe enough to impair daily functioning are reported by 37% of girls and 20% of boys. It also is estimated to affect approximately 5% of children, and the rate is higher in minority children and teens.

Although approximately 1 out of 4 or 5 children have a mental health disorder, less than 25% get any treatment, in large part because of inadequate screening and identification by primary care providers. Mental health disorders are as common now as childhood fractures. The reoccurrence rate is very high in children and teens who have a first episode of major depressive disorder, approximately 60% to 70%, which makes early detection and intervention critical with the first episode.

Medscape: How can pediatric nurses best detect childhood and adolescent depression in the primary care setting?

Dr. Melnyk: The best way to detect depression is to screen routinely for it. The latest gold standard, evidence-based recommendation from the United States Preventive Services Task Force, states that adolescents 12 to 18 years of age should be screened for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up.

However, the problem is that many primary care practices do not have these services or even access to them, especially in rural and underserved areas, which places the burden on primary care providers to treat these affected children and teens, often without adequate knowledge and skills. Even mild or subclinical depression has been recognized as a significant mood disorder and one of the strongest predictors of future episodes of depression, so it is important to detect children and teens with mild symptoms.

Medscape: What screening measures are most effective? How time-intensive, cost-effective, and accurate are these screening tools?

Dr. Melnyk: We have excellent screening tools that have substantial evidence to support their validity and reliability — namely the Center for Epidemiological Studies Depression Scale for Children (CES-DC); the Keep Your Children/Yourself Safe and Secure (KySS) Guide to Child and Adolescent Mental Health Screening, Early Intervention, and Health Promotion; and the Patient Health Questionnaire (PHQ-9 for Adolescents). All of these tools are free and available at the Bright Futures Web site.

These tools take only 3 to 5 minutes to complete and have good sensitivity and specificity in detecting depression. However, it is important to remember that screening does not replace good, sensitive clinical interviewing. If a screen is positive, then a thorough interview should be conducted by the primary care provider.

Medscape: What strategies are most effective for managing child and adolescent depression in primary care?

Dr. Melnyk: Findings from studies have indicated that the best strategy for managing child and adolescent depression is cognitive behavior therapy (CBT), in combination with selective serotonin reuptake inhibitor (SSRIs) medications, like Prozac or Zoloft, if the adolescent is moderately or severely depressed and when CBT alone is not producing positive outcomes. For mild to moderate depression, CBT should be tried first, and if the patient is not responsive, then SSRI [therapy] is started.

We have to remember, however, that many primary care practices do not have access to providers who deliver CBT, and teens often do not follow through with referrals to mental health professionals made by their primary care providers. There are recently published guidelines for the management of adolescent depression that can assist primary care providers in their assessment and management of adolescent depression in primary care.

I have developed and pilot tested a 7-session, brief, cognitive behavior skills-building intervention program for depressed teens that is showing promising results and that can be delivered in 20 to 25 minutes, making it feasible to deliver in the context of [certain] primary care settings, including school-based health settings. The program is called COPE (Creating Opportunities for Personal Empowerment) and is manualized so that, after 1 training session, nurses practitioners, physicians, and nurses can deliver it to depressed teens in their [own] clinical settings.

This session is part of a 15-session COPE/Healthy Lifestyles TEEN (Thinking, Emotions, Exercise and Nutrition) program that my research team is now testing with 800 adolescents in Phoenix area high schools. From pilot work using the COPE TEEN program, we have seen substantial drops in depression and anxiety in adolescents.

Medscape: What role should cognitive-behavioral skills building play in overall management, and how can these best be implemented?

Dr. Melnyk: In cognitive-behavioral skills building, we teach teens that they way they think affects they way they feel and the way they behave. As part of these skills, we teach the ABCs — how to recognize an antecedent event that leads to a negative belief or pattern of thinking, and the consequence of that negative belief, which typically is depressive or anxiety symptoms. We then teach the teen how to turn their negative thoughts into positive ones so that they feel better and have fewer depressive symptoms.

In cognitive-behavioral skills building, we also teach teens problem-solving and coping skills that include stress reduction strategies. All primary care providers can be taught how to implement cognitive-behavioral skills building in an efficient manner with children and teens in primary care practices.

Medscape: What is the role of the pediatric nurse in identifying depression and implementing treatment?

Dr. Melnyk: Pediatric nurse practitioners and pediatric nurses should lead the way in screening for and assessing children and teens for mental health problems, including depression. They have long been on the forefront of health promotion, including mental health promotion, by teaching children and teens good coping skills and stress reduction techniques. Given the high prevalence of mental health disorders in children and teens, cognitive-behavioral skills building should be taught to all children and teens as a prevention and intervention strategy.

Medscape: Thank you, Dr. Melnyk; this has been quite informative. Is there anything you would like to add?

Dr. Melnyk: For any child or teen with any level of depression, all health providers need to screen for suicide, because the majority of those who commit suicide have a history of depression.

We must ask the questions and screen routinely for this major public health problem in primary care practice. It also is important to remember that depression is often comorbid with other mental health disorders, such as anxiety and substance abuse.

There is a KySS online continuing education, faculty-mentored fellowship program to assist nurse practitioners, nurses, physicians, and other healthcare providers in furthering their skills in the assessment and evidence-based management of child and adolescent mental health problems.

The KySS program is offered by the Arizona State University College of Nursing and Health Innovation, in partnership with the NAPNAP KySS program. The KySS Guide to Mental Health, published by NAPNAP, is a wonderful resource with tools to help providers better screen for, identify, and intervene for children and teens with mental health disorders.

Dr. Melnyck chairs NAPNAP's KySS program and edited the KySS Guide to Mental Health, donating her honorarium back to the KySS program.

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