Depression A Short Course Learning Objectives To review

Depression: A Short Course

Learning Objectives • To review the diagnostic criteria and clinical reality of adolescent depression • Perform a depression assessment, based on the AAP-approved Guide. Lines for Adolescent Depression in Primary Care (GLAD-PC) • Analyze two clinical case vignettes • Use standardized questionnaires as aids in assessment of depression. • To score and interpret standardized questionnaires applied to case vignettes Copyright © The REACH Institute. All rights reserved.

Major Depressive Disorder in Adolescents: Common in the Primary Care Setting • Prevalence: – Children: 2%--1: 1 M: F – Adolescence: 4 -8%– 1: 2 M: F Significant burden of illness on patients and families • High rates of depression in primary care settings • (Cheung et al. , 2007) • 50% of youth with depression missed in primary care settings (Chang et al. , 1988, Kramer & Garralda, 1998) • USPSTF recommends screening for depression in adolescents in primary care Copyright © The REACH Institute. All rights reserved.

Adolescent Depression – DSM-5 A. Five (or more) of the following symptoms for a 2 -week period and representing a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (1) Depressed mood. Note: In children and adolescents, can be irritable mood. (2) Diminished interest or pleasure in all, or almost all, activities (3) Appetite and weight changes (4) Sleep pattern disruption (5) Psychomotor agitation or retardation (6) Fatigue or loss of energy (7) Feelings of worthlessness or excessive or inappropriate guilt (8) Diminished ability to think or concentrate, or indecisiveness (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide Copyright © The REACH Institute. All rights reserved.

Adolescent Depression (continued) B. The symptoms do not meet criteria for a mixed episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e. g. , a drug of abuse, a medication) or a general medical condition (e. g. , hypothyroidism). E. The symptoms are not better accounted for by bereavement, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. Copyright © The REACH Institute. All rights reserved.

Depression Mnemonics Sig: Energy CAPs A B C D E F G H I DEAD SWAMP Sleep Disorder Anhedonia (decreased interest in activities) Depressed mood Interest Deficits (anhedonia) Bad mood Energy loss or fatigue Guilt (feelings of worthlessness) Concentration Anhedonia Energy deficit Death thoughts Concentration problems Energy deficits Sleep Disturbances (+/-) Appetite changes (+ or -) Food intake changes Worthlessness of guilt Psychomotor retardation or agitation Guiilt/self-esteem Appetite or weight change Suicidality Hyper/hypoactive motor behavior Mentation (concentration) decreased Insomnia Psychomotor agitation or retardation Copyright © The REACH Institute. All rights reserved.

Adolescent Mood Disorders: DSM-5 • Major Depressive Disorder • Persistent Depressive Disorder • Depressive Disorder Unspecified • Adjustment Disorder with Depressed Mood • Later Units – Bipolar Disorder – presented in Unit I – Disruptive Mood Dysregulation Disorder – discussed in Units I & J Copyright © The REACH Institute. All rights reserved.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Development Process • Initial partnership between the Center for the Advancement of Children’s Mental Health, Columbia University and University of Toronto • Focus groups: primary care providers, parents, and youth (Toronto, and Montreal) • Consensus Survey of PCPs, depression specialists (MD, Ph. D) • Systematic Evidence based Literature Reviews • Consensus Workshop with 80 participants Copyright © The REACH Institute. All rights reserved.

GLAD-PC Guidelines: Identification/Surveillance Systematically look for patients with depression risk factors* *Update March 2009: US Preventive Services Task Force recommends universal SCREENING for adolescents 12 -18 y. o. , when systems are in place to ensure accurate diagnosis, psychotherapy (CBT), and follow-up. Copyright © The REACH Institute. All rights reserved.

Depression Risk Factors • High family loading (family history of depression) • Stressors: – Loss, abuse, neglect, trauma, ongoing conflict and frustrations, divorce, death (family/friend) • Co-existing disorders (e. g. , anxiety, substance abuse, ADHD, eating disorders), • Medical illness (e. g. , diabetes, asthma), • Biological and sociocultural factors Copyright © The REACH Institute. All rights reserved.

GLAD-PC Guidelines: Assessment/Diagnosis • PC clinicians should evaluate for depression in high-risk children or adolescents as well as those who present with emotional problems as the chief complaint. Copyright © The REACH Institute. All rights reserved.

GLAD-PC Guidelines: Assessment/Diagnosis • Use diagnostic criteria established in the DSM (IV, now 5) • Use standardized depression tools • Conduct direct interviews with the patients and families/caregivers • Assess functional impairment Copyright © The REACH Institute. All rights reserved.

GLAD-PC Toolkit (see www. GLADPC. org) • Screening and Assessment: – Screening/Assessment Tools § Columbia DISC Depression Scale (CDS) § Patient Health Questionnaire-Modified (PHQ-9) § Kutcher Adolescent Depression Scale § Beck Depression Inventory (not in toolkit) • Administer depression screener (PHQ-9, CDS, KADS, CES-D, BDI ($), CDI ($), Other) Copyright © The REACH Institute. All rights reserved.

How to Recognize the Moods of an Adolescent HAPPY DEPRESSED EXCITED ANXIOUS MANIC SUICIDAL

Clinical Vignette – Jennifer Copyright © The REACH Institute. All rights reserved.

Group Discussion - Jennifer • Workbook G 1. 1 -1. 7 • Review CDS-child. What does this score mean? • Review CDS-parent • Review PHQ-modified. What does the score mean? • Review DSM-5 checklist. Does she meet DSM criteria for MDD? Copyright © The REACH Institute. All rights reserved.

Table Activity- Jennifer 1. Review her CGAS and score it as group. 2. On the flipcharts, your scribes will write: – CGAS score as a single number or range – Any required lab tests – Differential diagnoses 5 minutes!! Copyright © The REACH Institute. All rights reserved.

Clinical Vignette – David Copyright © The REACH Institute. All rights reserved.

Table Activity: Using Assessment Tools • See DAVID’s questionnaires (G 1. 8 – 2. 4) • Your group has 7 minutes to: – Review David’s Columbia Depression Scale (CDS) and PHQ-M. Discuss his “scores” in the context of the vignette. – Review David’s parental CDS. Discuss the results as they apply to the vignette and what you know about teens. – Reconcile the scales with the vignette. – Fill out the clinician DSM checklist for David. Discuss each criterion, in the context of the vignette, as present or absent. – SCRIBES - Please write on your flipchart: 1. Does David meet criteria for MDD? (Y/N) 2. Differential diagnoses for David? 3. David’s CGAS score? Unit G: Short Course Depression Copyright © The REACH Institute. All rights reserved.

Group Discussion • Discuss together: – What additional information do you want before initiating the treatment planning phase? – Lab Tests? – ROS and further focused PE? – Additional sources of history/functioning levels? Copyright © The REACH Institute. All rights reserved.

Assessment Summary • Screen all youth for depression, and carefully evaluate all screen positives, other high-risk children and youth, and those presenting with emotional problems as the chief complaint. • Assess for depressive symptoms based on diagnostic criteria established in the DSM 5 or ICD 10; and use standardized depression tools to aid your assessment. • Conduct face to face interviews in combination with standardized assessment tools, and use multiple sources of information ( e. g. teachers, guidance counselors) to obtain a comprehensive diagnostic picture. Copyright © The REACH Institute. All rights reserved.

REMINDER: Please fill out Unit G evaluation Copyright © The REACH Institute. All

Getting it Paid For: Self-Study Do you know how to code these cases so

Jennifer’s Visit: Diagnosis n Major Depressive Disorder, Single Episode, Mild: 296. 21 n Major Depressive Disorder. Single Episode, Unspecified: 296. 2 Copyright © The REACH Institute. All rights reserved.

Jennifer’s Visit: 99215 n Complex Medical Decision Making: – – – n Medical Diagnosis: Extensive Data: Extensive Risk: High History: – – – HPI: 4+ ROS: 10+ PFSH: 2 Copyright © The REACH Institute. All rights reserved.

Jennifer’s Procedures: 96110 Columbia DISC Depression Scale (CDS): Jennifer, Mother n Pediatric Health Questionnaire. Modified: Jennifer n n 3 standardized rating scales administered, scored and interpreted Copyright © The REACH Institute. All rights reserved.

Jennifer’s Visit n n n 99215 -25 (3) 96127 n n n 99215 96127

David Visit 1: Diagnosis n Major Depressive Disorder, Single Episode, Moderate: 296. 22 Major Depressive Disorder, Single Episode, Unspecified: 296. 2 (Other Suspected Mental Condition: V 71. 09) n Copyright © The REACH Institute. All rights reserved.

David’s Visit: 99215 n Major depressive disorder meets the criteria for complex medical decision making • High risk for morbidity/mortality • Laboratory or other diagnostic tests requiring review (rating scales) • Extensive differential dx. to consider Copyright © The REACH Institute. All rights reserved.

David’s Visit: 99215 n Complex Medical Decision Making: – – – n Medical Diagnosis: Extensive Data: Extensive Risk: High History: – – – HPI: 4+ ROS: 10+ PFSH: 2 Copyright © The REACH Institute. All rights reserved.

David’s Visit: Prolonged Services, Too? Visit took 53 minutes -13 minutes longed than the 40 minutes expected for 99215 n 99354: Prolonged physician service in office/out-pt. setting in excess of usual service, first hour (30 -74 minutes) No prolonged service code. (See Appendix) n Copyright © The REACH Institute. All rights reserved.

Telephone Care n This follow-up call would properly be considered post-service work for the visit. – Discussing results of a test directly obtained after the encounter – Call was within 7 days of the encounter and the next visit was within a few days of the call – See Appendix Copyright © The REACH Institute. All rights reserved.