Diagnosis & Management of Adolescent Depression Stephen M Diagnosis & Management of Adolescent Depression Stephen M. Strakowski, MD Associate Vice President, Regional Mental Health Professor & Chair, Psychiatry Dell Medical School University of Texas - Austin Title slide.

Strakowski COI statement DSMB Chair for Sunovion studies. Medscape (WebMD) video ‘blogger’.

Major Depression in Teens Affects 10% of 15-25 year olds Rates double between ages 13-18 years. <50% of affected youth get meaningful treatment Even less in youth of color Early peak in suicide in this age range Young adults in general Late adolescence in males specifically More likely to be onset of other conditions Bipolar disorder, schizophrenia, PTSD Strakowski SM, Nelson EG. Major Depressive Disorder. Oxford U. Press, NY, NY 2015 Merikangeas KR, et al. JACAP 2010; 49:980-989. Cummings JR, Druss BG. JACAP 2010; 50:160-170.

DSM 5 criteria for Major Depression >5 of the following for 2 weeks and a change from previous *Depressed (or irritable in teens) mood most of the day, nearly every day *Anhedonia Significant weight loss or change in appetite (fall of growth curve). Insomnia or hypersomnia nearly every day. Psychomotor agitation or retardation Fatigue or loss of energy nearly every day. Feelings of worthlessness or excessive guilt. Decreased concentration/indecisiveness Recurrent thoughts of death or suicide B. Clinically significant distress or impaired functioning. C, D, E. Not due to substance or to another medical or psychiatric condition. Specifiers – With: anxious distress, mixed, melancholic, atypical, mood-congruent psychotic, mood-incongruent psychotic features or cataonia; or with peripartum onset or seasonal pattern. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright © 2013). American Psychiatric Association.

Diagnostic differences in Teens More irritability and agitation. Less neurovegetative disruption (growth curve). More suicidality than early/middle adults. More likely to be harbinger of other conditions Bipolar disorder, alcohol/drugs, trauma Differences from ‘Teenage Angst’ Peer withdrawal, suicidality, neurovegetative Failure at previous areas of importance to teen Evolves during adolescence with prefrontal changes. Strakowski SM, Nelson EG. Major Depressive Disorder. Oxford U. Press, NY, NY 2015

Successful Treatment: 7 Key components Comprehensive Assessments* Ongoing safety evaluations* Setting treatment goals agreeable to teens! Agreed upon treatment plan to meet goals* A good support network (ideally peers) Mood charting Systematic, meaningful appointments Strakowski SM & Nelson EB. Major Depressive Disorder. OAPL Oxford University Press, NY 2015. Strakowski SM. Bipolar Disorder. OAPL Oxford U. Press, NY 2014

Comprehensive Assessments Systematic psychiatric assessment (checklist) Identify medical/psychiatric causes Identify relevant family history (bipolar disorder) Assess stressors (consider checklist) Assess drug/alcohol use; don’t forget smoking Suicide assessment Good medical evaluation Strakowski SM & Nelson EB. Major Depressive Disorder. OAPL Oxford University Press, NY 2015. Strakowski SM. Bipolar Disorder. OAPL Oxford U. Press, NY 2014

Suicide Risk: Safety Evaluation Risk Factors Prior suicide attempts Family history of suicide Suicidal ideation Hopelessness Drug/Alcohol abuse Anxiety/Panic attacks Psychosis Personality disorder Recent loss/major life stressor Medical illness Protective Factors Supportive family/children at home Strong religious beliefs Strong social support Future oriented Good coping skills Ongoing mental health care Limited access to highly lethal methods of suicide (e.g., guns) Strakowski SM & Nelson EB. Major Depressive Disorder. OAPL Oxford University Press, NY 2015. Strakowski SM. Bipolar Disorder. OAPL Oxford U. Press, NY 2014

Agreed upon treatment plan to meet goals Set goals meaningful to the teen Try managing cause alone vs. start treatment Three major choices Therapy only (stressors, functional goals) Meds only (medical or idiopathic, symptom goals) Combination See patient again within 2 weeks of initiating One change at a time PCPs will manage most depression Dose adequately Be patient and understand response Complex or failed 2 trials consider referral Strakowski SM & Nelson EB. Major Depressive Disorder. OAPL Oxford University Press, NY 2015. Strakowski SM. Bipolar Disorder. OAPL Oxford U. Press, NY 2014

Fluoxetine in Pediatric Depression Treatment for Adolescents with Depression (TADS) Study 439 randomized teens age 12-17 years CBT v. fluoxetine v. combination Response rates: Fluoxetine + therapy 71% > Fluoxetine alone 61%> Therapy alone 43% Placebo alone 35% March J et al. JAMA. 2004 Aug 18;292(7):807-20.

Antidepressant treatment response 6-8 weeks Mood Time Treatment starts

Antidepressant treatment response 6-8 weeks Mood Time Treatment starts

Antidepressant treatment response 6-8 weeks Mood Time Treatment starts

TAY Approved Antidepressants      Brand Name Generic Name Approved Age      Anafranil clomipramine 10 and older (for OCD) Celexa citalopram 18 and older      Effexor venlafaxine 18 and older Lexapro escitalopram 18 and older      Luvox fluvoxamine   8 and older (for OCD)      Paxil paroxetine 18 and older      Prozac fluoxetine 7 and older (for depression) Remeron mirtazapine 18 and older      Serzone nefazodone 18 and older      Sinequan doxepin 12 and older      Tofranil imipramine   6 and older (for bed-wetting)      Wellbutrin bupropion 18 and older      Zoloft sertraline   6 and older (for OCD)

SSRIs in Children Advisory 2004: FDA orders black box warning on SSRIs Meta-analysis of 372 studies increased from 2-4% in SI, no attempts, if <18. 2007: modified to acknowledge depression increased suicide risk (15% in adults). 2004: decreased SSRI prescribing Subsequent increased drug poisonings?! Risk of untreated depression>>risk of SSRIs SSRIs are effective, but monitor use.

Psychotherapy for Adolescent Depression Psychotherapy is recommended for treatment of adolescent depression Cognitive Behavioral Therapy (CBT): best evidence Interpersonal Therapy (IPT): good evidence Psychodynamic Psychotherapy: limited evidence Lifestyle management: minimal evidence, but low risk Strakowski SM & Nelson EB. Major Depressive Disorder. OAPL Oxford U. Press, NY 2014. Clark et al. Am Fam Physician 2012; 86:442-448.

A Brief Guideline for Treatment of Adolescent Depression Optimize current or start new treatment 1st line: fluoxetine, established SSRIs, CBT, IPT 1bst line: SNRIs, Bupropion 2nd line: mirtazapine, levomilnacipran, vilazodone, vortioxetine 3rd line: ECT, rTMS, VNS, DBS, TCAs, MAOIs, ?Ketamine Switch (no response in 4-6 weeks) Augment (partial response) 1st line: Antidepressant combination, lithium, CBT, IPT 2nd line: thyroid hormone, approved atypical antipsychotic 3rd line: stimulants, ECT, Ketamine, rTMS 3 drug maximum (combos probably need referral) Avoid frequent changes (be systematic)

Questions?