Depression: A Short Course Hook: Consider talking about a case you know of where depression assessment was essential i.e. where it didn’t happen and there was a bad outcome, or did happen and you made a difference, etc. Transition point: So what are we going to do in this unit? Unit G: Short Course Depression

Learning Objectives To review the diagnostic criteria and clinical reality of adolescent depression Perform a depression assessment, based on the AAP-approved GuideLines 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 As the presenter before told you, you’re going to learn about how to do a great depression assessment. What is it? We’re going to learn about pediatric specific guidelines GLAD PC We’re going to see some live cases of two depressed teens and we’re going to practice how to assess it and learn how to do a great assessment. Transition point: So why would you want to do all of this? Unit G: Short Course Depression

Hidden Slide – Time Table Total time: 50 minutes Goals/Agenda: 3’ Lecture: 12’ Vignettes: 20’ Jennifer’s info reviewed: 5’ Table Activity: David’s assessment: 5’ David’s feedback review: 5’ Unit G: Depression: A Short Course Unit G: Short Course Depression

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 Look how common these conditions are in primary care. And look how often they’re missed. These facts are why now depression screening is recommended for kids in primary care. Transition point: So if you’re going to screen for it, how do you identify it? Will you just know it when you see it? Unit G: Short Course Depression

Adolescent Depression – DSM-5 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 Well, there are DSM criteria. Notice that depressed mood or loss of interest is essential. Two weeks long at least. And this long list of nine symptoms, of which you have to have five. Transition point: is that all? Not quite. Unit G: Short Course Depression

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. Actual DSM-5 Unit G: Short Course Depression

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 Take your pick. SIG E CAPS, A-I, or DEAD SWAMP. Transition point: How about other forms of depression? Unit G: Short Course Depression

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 There are various forms of depression, not just major depression which we have just been talking about, but persistent depression that becomes chronic with less severity. And of course, there are depression variants that don’t fully confirm to the criteria. Depressive disorder unspecified, as you see here. Or brief reactions in response to a stress. In later units, we’ll cover there other topics. Transition point: If we’re going to evaluate a child or youth for depression, how do we go about it? Are there any guidelines? Background ( For your information only: Do NOT repeat or read): Persistent Depressive disorder : includes both Dysthymic Disorder characterized by chronic depression, but with less severity than a major depression, as well as prolonged and chronic MDD. The essential symptom for dysthymic disorder is an almost daily depressed mood for at least two years, but without the necessary criteria for a major depression. Low energy, sleep or appetite disturbances and low self-esteem are usually part of the clinical picture as well.  Disruptive Mood Dysregulation Disorder: not to be covered here. Will come up Unit G: Short Course Depression

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, PhD) Systematic Evidence based Literature Reviews Consensus Workshop with 80 participants Funny you should ask! In fact, the guidelines for adolescent depression in primary care GLAD PC have been developed through a very extensive process. Transition point: What are some of the specific recommendations from GLAD PC for evaluation and assessment? Unit G: Short Course Depression

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. Look for kids who are at risk! And even more recently, do it systematically through a screening procedure. Transition point: So what are potential risk factors for depression? Unit G: Short Course Depression

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 Take a look. Anything here surprise you? Or can you think of any others? One or two hands if raised to get feedback / response. Transition point: So what do you do if you find a kid who’s screened positive or who appears to have depression risk factors? Background – Do not repeat if parent depressed, children have 3X risk of depression. AACAP DEPRESSION PRACTICE PARAMETER: In fact, the single most predictive factor associated with the risk of developing MDDis high family loading for this disorder (Nomura et al., 2002; Weissman  et al., 2005). The onset and recurrences of major depression may be moderated or mediated by the presence of stressors such as losses, abuse, neglect, and ongoing conflicts and frustrations. However, the effects of these stressors also depend on the child’s negative attributional styles for interpreting and coping with stress, support, and genetic factors. Other factors such as the presence of comorbid disorders (e.g., anxiety, substance abuse, ADHD, eating disorders), medical illness (e.g., diabetes), use of medications, biological, and sociocultural factors have also been related to the development and maintenance of depressive symptomatology (Caspi et al., 2003; Costello Unit G: Short Course Depression

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. We assess them, and do a careful diagnostic workup. Transition point: How should we assess them? What does GLAD PC say? Unit G: Short Course Depression

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 Well, don’t make up your own criteria. Use the DSM 4 or 5. And what else? Screening tools, as we’re beginning to know. But as we learned yesterday, what else do we need to rely on? Can screening tools give us a false negative? Or a false positive? Yes. So direct interviews and using our non-verbal observational skills. Transition point: So, are you going to have to go out and chase down all the tools you will need to do a good job? Unit G: Short Course Depression

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) No. In fact, there are all kind of tools in the public domain that the GLAD PC Tool developers have assembled for you. These tools can both help you screen for depression and help you do a formal assessment of depression. Transition point: Why would we need such tools? Aren’t our clinical instincts enough? Unit G: Short Course Depression

How to Recognize the Moods of an Adolescent HAPPY DEPRESSED EXCITED Well, as you can see here, if you are really good with your non-verbal skills, you can easily differentiate the six moods of this adolescent. Right? Transition point: Happily, our local host has arranged for one of his own patients to come in this morning. Her name’s Jennifer. Let’s take a look. ANXIOUS MANIC SUICIDAL Unit G: Short Course Depression

Hidden Slide Presenter tells participants to carefully compare and contrast two different kids: Jennifer and David, and see what differences they detect in the two cases. Jennifer’s case will be first. Unit G: Short Course Depression

Clinical Vignette – Jennifer Unit G: Short Course Depression

Hidden Slide Presenter asks group to turn to workbook G1.1-1.7 for completed questionnaires on Jennifer, as well as a completed CGAS and DSM-5 checklist. Presenter quickly reviews Jennifer’s scales, diagnosis, and impairment level. Presenter points out that parents know less about their kids depression and usually underreport symptoms– If parents say kid is depressed, highly likely that kid is. Unit G: Short Course Depression

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? Unit G: Short Course Depression

Table Activity- Jennifer Review her CGAS and score it as group. On the flipcharts, your scribes will write: CGAS score as a single number or range Any required lab tests Differential diagnoses 5 minutes!! Transition point: Let’s do another case. This one will be a little bit harder. Unit G: Short Course Depression

Unit G: Short Course Depression Hidden Slide Important point for Presenter: If MDD criteria met, it is MDD and not adjustment disorder, even with a stressor Adjustment disorder definitional issues: An Adjustment Disorder is a debilitating reaction, usually lasting less than six months, to a stressful event or situation. The distress is in excess of what would be expected from exposure to the stressor, and must have significant impairment in social, occupational or educational functioning. The stress-related disturbance DOES NOT meet the criteria for another specific disorder. Thus: if a youth has an apparent response to a stressor and now has prolonged symptoms (e.g, > 2 weeks), such that he/she meets MDD criteria, MDD should be diagnosed rather than Adjustment Disorder w/Depressed Mood.  Unit G: Short Course Depression Unit G: Short Course Depression

Clinical Vignette – David Unit G: Short Course Depression

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. Unit G: Short Course Depression

Copyright ©2014 The REACH Institute. All rights reserved. Hidden Slide Presenter elicits answers from tables. Key points: David is a hostile teen denying all symptoms Parents aware of some but not all his symptoms David does meet criteria for MDD (go through each criterion) with moderate impairment (CGAS around 50), but must“read”into his demeanor: irritability, thoughts of death, etc. Differential includes substance abuse Put on next slide and continue group discussion Unit G: Short Course Depression Copyright ©2014 The REACH Institute. All rights reserved. Unit G: Short Course Depression

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? Transition point: All right. Let’s summarize what we’ve learned. Unit G: Short Course Depression

Unit G: Short Course Depression Hidden Slide Urine tox screen Discuss Thyroid Function Tests (TFTs) plus/minus TFTs plus/minus—There appears to be a clinical consensus derived from recent studies (TADS) which suggests there is limited benefit to getting routine TFTs If mood symptoms are caused by low thyroid hormone, physical symptoms are usually present… School/educational/developmental history Neuro exam, BP (Is this steroids?) TFTs plus/minus—there appears to be a clinical consensus derived from recent studies (TADS) which suggests there is limited benefit to getting TFTs…if mood symptoms are caused by low thyroid hormone, physical symptoms are usually present… Unit G: Short Course Depression Unit G: Short Course Depression

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. Screen all kids. Pay special attention to high risk kids, and routinely assess depressive symptoms using a tool. But the tools are fallible and cannot be used alone to make the diagnosis of depression. Your skills in doing a great face-to-face assessment, reading the child’s non-verbals, meeting with the parent alone, meeting with the youth alone, as well as meeting together, are what you’re going to need to do a thorough assessment….which you can do! Transition point: So let’s assume you’ve got a case. What are you going to do now? Fortunately, Dr. X is here and now we’re going to work on learning that. Unit G: Short Course Depression

Please fill out Unit G evaluation REMINDER: Please fill out Unit G evaluation Unit O: Training is Beginning

Getting it Paid For: Self-Study Do you know how to code these cases so you will get paid? Do you know when to use these coding variations? Unit G: Short Course Depression

Jennifer’s Visit: Diagnosis Major Depressive Disorder, Single Episode, Mild: 296.21 Major Depressive Disorder. Single Episode, Unspecified: 296.2 Unit G: Short Course Depression

Jennifer’s Visit: 99215 Complex Medical Decision Making: History: Medical Diagnosis: Extensive Data: Extensive Risk: High History: HPI: 4+ ROS: 10+ PFSH: 2 Unit G: Short Course Depression

Jennifer’s Procedures: 96110 Columbia DISC Depression Scale (CDS): Jennifer, Mother Pediatric Health Questionnaire-Modified: Jennifer 3 standardized rating scales administered, scored and interpreted Unit G: Short Course Depression

Jennifer’s Visit 99215-25 (3) 96127 99215 96127 96127-59 99215-25 96127-76 Unit G: Short Course Depression

David Visit 1: Diagnosis Major Depressive Disorder, Single Episode, Moderate: 296.22 Major Depressive Disorder, Single Episode, Unspecified: 296.2 (Other Suspected Mental Condition: V71.09) Unit G: Short Course Depression

David’s Visit: 99215 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

David’s Visit: 99215 Complex Medical Decision Making: History: Medical Diagnosis: Extensive Data: Extensive Risk: High History: HPI: 4+ ROS: 10+ PFSH: 2

David’s Visit: Prolonged Services, Too? Visit took 53 minutes -13 minutes longed than the 40 minutes expected for 99215 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)

Telephone Care 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