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Treatment of Depression in Primary Care

• Kelley Victor, MD• Justin Schreiber, DO MPH FAAP

TiPS conference 5/22/2020

Overall Goals and Objectives

• Identification of Depression• Screening and clinical interview

• Depression Interventions in Primary Care• Non-pharmacologic treatment

• Pharmacologic treatment

• Initiation of medication

• Medication management

• discontinuation

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Depression:Incidence/Prevalence

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In 2015, 30% of H.S. students reported feeling sad or hopeless in the previous 12 months (CDC, 2016)

20% of teens will become clinically depressed prior to adulthood

5-10% of teens have sub-syndromal symptoms

Female to male ratio is 1:1 for children and 2:1 for adolescents

Point prevalence for adolescents with depression being seen in primary care is up to 28% (GLAD-PC:II, 2007)

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Depression: SIG-E-CAPS• Depressed and/or irritable mood

PLUS….• Sleep disorder• Interest deficit (anhedonia)• Guilt (worthlessness, hopelessness,

regret)• Energy deficit • Concentration deficit• Appetite changes• Psychomotor agitation or retardation• Suicidality

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PHQ-9

Wide spread testing in primary careSelf-report formsExclusive for depression5 minutes to complete, seconds to scorePublic availabilityAccepted as a gold standard for adolescentsSignificant score is 11 or greater(15 increases

specificity)Always note questions about lethality!

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Mark• 15 year old honors student brought by

parents to your office because of increased irritability. Since a break-up 8 months ago, he has been withdrawing to his bedroom to play video games every night, even reluctant to go out with friends. He is angry around family. He still appears to enjoy himself when he is out at social events, but doesn’t want to sign up for baseball, stating that he isn’t good enough.

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Mark’s PHQ-9

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Group Discussion• What diagnostic criteria are

indicative of depression vs. what else could be on the differential?

• Is he just a typical teenager?

• What further questions would you ask?

• What additional work-up would you consider? 9

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Additional details from Mark

• Grades are dropping, can’t focus, not motivated.

• Feels like he can’t do anything right, what’s the point?

• Has lost 5 pounds recently due to decreased appetite.

• Isn’t using substances

• Symptoms present for the past 8 months but seem to be getting worse over the last 4 weeks.

• Denies suicidal thoughts.

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What is the diagnosis?

• A. Typical teenager

• B. Adjustment disorder

• C. Major depressive disorder

•D. Bipolar disorder

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If he is still enjoying himself at social events,

can he be depressed?

•A. Yes

•B. No

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Pearls of Assessment

• Establish basic rules from the beginning: confidentiality and when confidentiality must be broken

• Interview with caregiver and alone

• Emphasize with patient that there are no wrong answers

• Begin with social assessment

• Beware of assumptions, ask for clarification/examples

• Don’t lead them to the answer you want to hear

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Depression: Developmental Issues

• Pre-pubertal Children

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Adolescents

• Increased somatic complaints

• Psychomotor agitation• Mood-congruent

hallucinations• School refusal• Phobias, separation

anxiety, increased worry

• Irritability• Apathy: “I don’t care”

attitude• Low self esteem• Aggression / antisocial

behavior• Substance abuse• Can give a reliable

and detailed history

(GLAD-PC, 2007)

Group ChatWhat was on your differential for Mark?

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Differential Diagnosis Bipolar Disorder Drug and Alcohol Abuse: Depressive symptoms occur

in context of use ADHD: May occur co-morbidly with depression. Note

specifics of low self esteem, concentration, amotivation

Adjustment Disorder: If meets criteria for depression, diagnose it

Anxiety: Hard to be in a good mood when anxious all the time

Trauma: irritability, withdrawal

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Additional Differential Diagnosis to Consider…

• Thyroid: check growth and development, family history, low threshold

• Anemia (complaints of fatigue, irritability, diet concerns): check CBC

• CMP: general work-up

• Obstructive Sleep Apnea: noted abnormal snoring

• Adverse medication reaction: prescribed and non-prescribed

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Group ChatWhat symptoms would you ask about to assess

for bipolar disorder?

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Back to MARK

Mark has recently started therapy with a therapist in your office. He is about to come for a follow-up visit and you get a message from the therapist that he thinks Mark would benefit with starting a medication due to limited progress with therapy alone.

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Are you comfortable starting a medication

for Mark?

•A. Yes

•B. No

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Group Discussion• What are reasons to start a

medication for depression?

• What are the choices?

• What are special considerations and how to discuss each?

• What if there is a family history of mania?

• What if there is substance use?

• How do you talk with the patient and family about lethality and the black box warning? 21

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Treatment: Non-Pharm Interventions

• Psychoeducation!

• Depression is a change in mood that contributes to negativity, impaired functioning, low self-worth, amotivation, etc.

• Destigmatize

• Relaxation skills

• Including diaphragmatic breathing, progressive muscle relaxation, imagery, exercise, activities that are relaxing to patient

• Activation: aka “fake it ‘til you make it”

• Assist with Problem-solving

• Stressful situations that can be changed vs those that can’t

• Enhancing supports

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Treatment: Antidepressants• SSRIs: inhibit reuptake of 5-HT

• Fluoxetine(Prozac)

• Sertraline(Zoloft)

• Citalopram(Celexa)

• Escitalopram(Lexapro)

• When to start meds:• Symptoms are impairing functioning

• Unable to make progress in therapy due to severity of symptoms and/or minimal improvement with therapy and/or worsening despite therapy

• Degree of distress/severity of symptoms

• Making the choice: • Prozac and Zoloft have been the most studied in this population

• Family members’ response to SSRIs? Suggests a place to start…

• Prozac has a long half life

• Prozac less likely to cause sedation compared to Zoloft, Celexa and Lexapro

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Treatment: Rationale

• TADS: Treatment of Adolescents with Depression Study • N=439 children 12-17 years. 12 weeks of Prozac (10-40mg), CBT,

combo or placebo.

• Week 12: combo (73%) > meds alone (62%) > CBT alone (48%) > placebo (35%). Suicidal thinking decreased in all groups, greatest decrease in the combo group.

• Week 18: combo (85%) > meds alone (69%) = CBT alone (65%)

• Week 36: Combo (86%) = meds alone (81%) = CBT alone (81%)

• Take home: For moderate to severe depression, meds or meds+CBT accelerates response. Adding CBT increases safety by decreasing SI and attempts.

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Depression: Co-morbidity

• Depressed teens have higher rates of:• Risky sexual behavior

• Physical illness and complaints

• Depressed teens have lower rates of: • Satisfaction in relationships

• Attending higher education

• Up to 50% have 2 or more co-morbid psychiatric diagnoses (anxiety, dysthymia, substance use disorders, ADHD, disruptive disorders) (AACAP, 2007)

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What medication did you choose?

• A. Prozac (fluoxetine)

• B. Zoloft (sertraline)

• C. Celexa (citalopram)

•D. Lexapro (escitalopram)

• E. Wellbutrin (buproprion)

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Titration Schedules

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Medication Therapeutic range Starting dose Titration increments

fluoxetine 20-60 mg 10 mg daily x6 days then increase to 20 mg daily (can start at 5 mg daily)

5-10 mg

sertraline 50-200 mg 25 mg daily x6 days then increase to 50 mg daily (can start at 12.5 mg)

12.5-25 mg

citalopram 10-40 mg 5-10 mg daily 5-10 mg

escitalopram 5-20 mg 5 mg daily 5 mg

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Black Box Warning• Issued by FDA in 2004 after review of RCTs available.

• Retrospectively looked at occurrence of suicidal thoughts in depressed teenagers: • Not on medication: 2%

• On medication: 4%.

• This included suicide attempts but no completed suicides.

• Paxil has not been recommended since 2003.

• NIMH partially funded follow-up study in 2007 to review efficacy/risk of SSRIs. • Meta-analysis of 27 trials of pediatric MDD (15), OCD (6) and anxiety disorders (6).

• While there was increased risk difference of suicidal ideation/suicide attempt across all trials and indications for drug vs placebo, risk differences within each indication were not statistically significant.

• MDD: 2% vs 3% (NNH 112); OCD: 0.3% vs 1% (NNH 200); Anxiety: 0.2% vs 1%(NNH 143)

• NO completed suicides

• Conclusion of paper: benefits of antidepressants appear to be much greater than risks from SI.

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Depression & Suicide

• Untreated depression is the number one cause of suicide

• Over 90% of children and teens who complete suicide have a mental health diagnosis (Mental Health: A Report of the Surgeon General)

• In 2015, H.S. students (CDC, 2016)

• 18%reported seriously contemplating suicide

• 9% attempted at least once (in the preceding 12 months)

• Suicide is the #2 cause of death in the U.S. in those 10-24 years-old (NCHS)

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Case Continued

Mark returns one month later after you started Sertraline 50mg with persistent belly pains that has not gotten better. He doesn’t want to keep taking it and asks you to switch to something else.

After discussing a plan to switch to Citalopram, Mark’s mom asks if he will need to be on this medication forever.

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Group Discussion

• What are the side effects of SSRIs?

• When do you switch vs what can you do to alleviate side effects.

• How does one transition to another SSRI?

• When and how does one taper off an SSRI?

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SSRI Side Effects• GI: nausea, abdominal pain, diarrhea, weight loss, weight gain

• Headaches

• Easier bruising

• Sweating

• Light-headedness/dizziness

• Nervousness/restlessness

• Sleep difficulties: sedation/insomnia, vivid dreams

• Sexual dysfunction

• Irritability/activation

• Potential risk for suicidal thinking

• Precipitation of mania

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SSRI Cross-Titration

• Example of cross titration from sertraline 100 mg to citalopram 20 mg.

• Week 1: sertraline 75 mg, citalopram 5 mg

• Week 2: sertraline 50 mg, citalopram 10 mg

• Week 3: sertraline 25 mg, citalopram 15 mg

• Week 4: stop sertraline, citalopram 20 mg

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Will Mark be on this medication forever?

•A. Yes

•B. No

•C. Maybe

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Treatment: Duration

• Titrate medications as needed until efficacy and/or maximize dose

• Maintenance• Symptoms in remission AND 9-12 months of stability.

• Continue therapy, mastering skills

• Taper• Relatively stress-free time, “cruise control”

• SLOWLY

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Thank you!

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Bibliography

Brent, D., Kolko, D.( 1998). Psychotherapy: Definitions, mechanisms of action, and relationship to etiological models. Journal of Abnormal Child Psychology, 26(1), 17-25.

Brent, D., Emslie, G., Clarke, G., Wagner, KD., Asarnow, JR., Keller, M., Vitiello, B., Rit,z L., Iyengar, S., Abebe, K., Birmaher, B., Ryan, N, Kennard, B., Hughes, C., DeBar, L., McCracken, J., Strober, M., Suddath, R., Spirito, A., Leonard, H., Melhem, N., Porta, G., Onorato, M., Zelazny, J. (2008). Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial, JAMA, 299(8), 901-13.

Campo, J., Shafer, S., Strohm, J., Lucas, A., Cassesse, C., Shaeffer, D., Altman, H. (2005). Pediatric behavioral health in primary care: A collaborative approach. Journal of American Psychiatric Nurses Association, 11(5), 276-282.

Cheung, A., Zuckerbrot, R., Jensen, P., Ghalib, K., Laraque, D., Stein, R. (2007). Guidelines for adolescent depression in primary care (GLAD-PC):II. Treatment and ongoing management. Pediatrics, 120, 1313-1395.

Daviss,W., Birmaher, B., Melhem, N., Axelson, D., Michaels, S., Brent, D. (2006). Criterion validity of the mood and feelings questionnaire for depressive episodes in clinic and non-clinic subjects. Journal of Child Psychology and Psychiatry, 47, 927-934.

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Bibliography

Kovacs, M., (2003). Child’s depression inventory technical manual update (Rev ed.). North Tonawanda: Multi-Health Systems Inc.

March, J., Silvia S., Petrycki, S., Curry J., Wells K., Fairbank J., Burns B., Domino M.& McNulty S. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression, Treatment for adolescents with depression study (TADS) randomized controlled study. Journal of the American Medical Association, 292, 807-820.

Mental Health Report: A Report of the Surgeon General. (2008). Available on line at www.surgeongeneral.gov/library/mentalhealth/chapter3/sec5.html

Mental Health Report: A Report of the Surgeon General. (2008). Available on line at www.surgeongeneral.gov/library/mentalhealth/chapter3/sec6.html#autism

Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. (2007). Journal of American Academy of Child and Adolescent Psychiatry, 46:11, 1503-1526.

Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. (2007). Journal of American Academy of Child and Adolescent Psychiatry, 46:11, 107-121.

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Bibliography

The use of medication in treating childhood and adolescent depression: Information for the patients and families. Available on line at ParentsMedGuide.org

Weller, E., Weller, R., Rowan, A., Svadjian, H. (2002). Depressive disorders in children and adolescents. In Lewis M. (Ed.), Child and Adolescent Psychiatry (pp. 767-781). Philadelphia, Lippencott Williams & Williams.

Zuckerbrot, R., Cheung, A., Jensen, P., Stein, R., Laraque, D. (2007). Guidelines for adolescent depression in primary care (GLAD-PC): Identification, assessment, and initial management. Pediatrics, 120, 1299-1312.

“Fluoxetine, Cognitive-Behavioral Therapy, and Their Combination for Adolescents with Depression.” JAMA 2004. Vol 292, No. 7.

“The Treatment for Adolescents with Depression Study (TADS). Long-term Effectiveness and Safety Outcomes.” Arch Gen Psychiatry. Vol 64, No 10. 2007.

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Extra information

• Below are slides that we didn’t include in talk due to time limitations

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Depression: Risk Factors

• Family history of depression, mood disorders• Personal history of depression• Other psychiatric disorders (anxiety, externalizing disorders)• Substance use• Trauma• Psychosocial adversity• Chief complaint of emotional problem• Medical/Chronic Illness

(AACAP, 2007)

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Depression: Duration and Recurrence

• A teen depressive episode usually lasts 8+ months

• 20-60% recurrence 1-2 years after remission

• 70% recurrence after 5 years

• Recurrence can persist throughout life (AACAP, 2007)

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DSM 5 Criteria: Major Depressive Disorder

1. Sad, down, negative mood, empty feeling, hopelessness, irritability in children

2. Anhedonia, decreased interest or loss of pleasure

3. Changes in sleep

4. Changes in appetite

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Irritable, easily frustrated, argumentative. Focused on negative events, interprets events as negative, discounts positives. “I don’t care” attitude

Not enjoying or quitting activities; Subjective report or observed by others

May sleep/eat more or less.

DSM 5 Criteria: Major Depressive Disorder

5. Decreased concentration, decisiveness

6. Psychomotor agitation or retardation, observable by others

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Easily swayed by others, changes mind, can look similar to ADHD, amotivation

Complaints of feeling agitated, noted pacing/ increased negative energy, or “couch potato”, amotivation

DSM 5 Criteria: Major Depressive Disorder

7. Complaints of fatigue or decreased energy

8. Feelings of worthlessness or excessive/inappropriate guilt

9. Death wish, suicidal ideation

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Regardless of increased or decreased sleep

Negative about self, low self esteem, may feel responsible for events out of their control, discount positives and focus on negatives

May think family would be better off without them for fleeting moments or chronically think life isn’t worth it, want to hurt self but no plan, or have a plan, and/or intent

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DSM 5 Criteria: Bipolar Disorder DSM 5 criteria: Elevated mood + 3 Irritable mood + 4 Mania: 1 week Hypomania: 4 days

Distractibility Irresponsible behaviors, Inhibition is decreased Grandiosity (increased pleasurable activities)

Flight of ideas Agitation or increased goal directed Activity Sleep Talkative (increased)

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Behavioral Scales

• Screening tools are not diagnostic• Younger children may not understand questions

• Sometimes scores are elevated for reasons not related to depression

• Provide talking points

• Can be used to follow response to intervention• If scores are decreasing, you are on the right track with treatment.

• Helps patients to see their progress over time.

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Cognitive Behavior Therapy (CBT)

• Developed by Albert Ellis and Aaron Beck• Thoughts and behaviors affect feelings and automatic

thoughts (mind reading, forecasting, catastrophizing, discounting) • Feelings are not facts• Spiral thinking• Skills must be learned and practiced

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•Bottom Line50

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