Teen Depression Guidelines Call for Universal Screening

Pam Harrison

February 26, 2018

Updated guidelines for the diagnosis and treatment of depression in adolescents now endorse universal yearly screening from 12 years of age onward.

The new 2-part guideline, published online today in Pediatrics, was developed by the American Academy of Pediatrics, the Canadian Pediatric Society, and psychiatric associations from both countries.

"We know that more than 50% of cases of adolescent depression do not get identified, and even fewer get treated. [S]ince pediatricians and primary care providers are at the front-line, seeing these kids either for a well visit, school physicals, camp physicals, sports physicals, or just for common illnesses, they are in a really good position to identify depression as well as manage and treat it," Rachel Zuckerbrot, MD, lead author of the Guidelines for Adolescent Depression in Primary Care: (GLAD-PC), Part I, told Medscape Medical News. Zuckerbrot is an associate professor of clinical psychiatry, Columbia University Medical Center, New York City.

Nerissa Bauer, MD, MPH, a member of the guidelines' steering group and executive committee member of the American Academy of Pediatrics' section of development and behavioral pediatrics agrees, emphasizing that there is an urgent need for front-line physicians to get involved in identifying and caring for teenagers with depression.

"In the society in which we live, teens are much more prone to suffering from depression than ever, given social media and cyberbullying and the potential to be exposed to trauma every day in terms of social violence, gun violence, community violence," Bauer, an associate professor of pediatrics at Indiana University School of Medicine in Indianapolis, told Medscape Medical News.

"[D]epression is definitely a topic that primary care physicians need to be familiar with and to be able to talk sensitively about in a timely way with our families. It's just part of promoting the optimal wellness of our patients, and at least we have the ability to ask the question," she added.

First Step

The recommendation for universal screening is a departure from the previous guidelines, published a decade ago, and is the first step in a larger protocol that should be followed when a depressive disorder is suspected.

As was true for the 2007 guidelines, physicians need to evaluate teenagers for risk factors that increase the likelihood of depression, including a family history, substance use, and psychosocial adversity. Primary care providers, including pediatricians, should also seek comments from the teenager's family or caregivers in direct interviews with them.

"I think involving families is something that we've always supported," Zuckerbrot said. "So while it's really important for pediatricians to remember to interview the patient alone, it is also important for them to bring the family back in and to involve the family as well."

The new recommendations also put a new emphasis on collaborative care for teenage depression because "patients really benefit" when mental health and pediatricians work together, Zuckerbrot continued.

Again, Bauer concurs, noting that many practices are now relying more heavily on other professionals such as social workers and mental health therapists. "So the guidelines really emphasize the collaborative and interdisciplinary approach to getting teens help in a timely manner," she said. Education is critical, of course, not only for the patient but also for families, who need to understand what the teenager is going through and to recognize any warning signs that their child may be getting into trouble and needs to seek medical care.

Treatment goals need to be established as well, and expectations set in terms of how well a teenager should be functioning at home and at school. "All management should include the establishment of a safety plan," the guideline authors add. This safety plan needs to include concrete ways to restrict any means a teenager might have to suicide and how the family can rapidly communicate with providers if the teenager deteriorates or becomes actively suicidal or dangerous to others.

Treatment Initiation

According to the new guidelines, initiation of treatment depends on how severe the depression is. If the teenager has mild depression, physicians should consider a period of "active support and monitoring" before initiating evidence-based treatment with medication and psychotherapy. Only if symptoms persist should treatment be initiated.

During the last decade, evidence supporting antidepressant options has solidified, and evidence-based recommendations are well laid out in part 2 of the new guidelines.

In addition, cognitive behavioral therapy and interpersonal psychotherapy have been adapted for adolescents with depression and can be effective in helping resolve major depressive disorders. Ideally, Bauer says, medication and psychotherapy are used together, given that psychotherapies help teenagers develop the cognitive skills they will need to cope with depression, if it recurs, and may allow them to eventually discontinue antidepressant medication altogether.

For teenagers with more severe depression, or if they have a coexisting condition such as substance abuse, the authors suggest physicians consider consultation with a mental health specialist. "All pediatric patients being treated with antidepressants for any indication should be observed closely for clinical worsening, suicidality and unusual changes in behavior, especially during the initial few months of a course of drug therapy or at times of dose changes, either increases or decreases," the US Food and Drug Administration has warned in the past.

Thus, physicians must monitor teenagers for signs of any adverse event while treating them with antidepressant therapy. Physicians also need to assess how well teenagers are responding to treatment and to reassess them if there is no improvement after 6 to 8 weeks of treatment.

"Despite the 2007 guidelines, there are pediatricians who think it's not standard of care for them to be prescribing antidepressants, so I think it's important that with the newly revised guidelines, there should be an emphasis for pediatricians [and general practitioners] to realize that the [American Academy of Pediatrics] is supporting them, and at times, this can be standard of care," Zuckerbrot emphasized.

Bauer also supports the idea that front-line physicians should take responsibility for teenage depression in a major way, provided they feel comfortable doing so. "I think, in general, clinicians have every responsibility to identify an adolescent who is suffering from depression and to implement appropriate treatment, whether they themselves do it or refer out if they don't feel comfortable," Bauer reaffirmed.

"We just want to make sure we identify these children or teens as early as possible to get the best outcomes," she stressed.

Zuckerbrot works for CAP PC, Child and Adolescent Psychiatry for Primary Care, now a regional provider for Project TEACH in New York State. She is also on the steering committee as well as faculty for the REACH Institute and she and another guideline author receive book royalties from Research Civic Institute. Bauer has disclosed no relevant financial relationships.

Pediatrics. Published online February 26, 2018. Part 1, Part 2

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