1. Pediatric Depression and Suicide: An Update for School Nurses W. Burleson Daviss, MD Dept. of Psychiatry University of Texas Health Science Center at San Antonio

2. Objectives Learn about burdens associated with pediatric depression and suicide Learn about strategies for assessing pediatric depression Genetic and social risk factors Clinical signs, comorbidity, differential diagnosis Assessment strategies in a school-based setting. Discuss treatment options for pediatric depression (providing essential information for school nurses).

4. Symptoms of Depression-- SIGECAPS: Sleep problems Interests decreased Guilty, worthlessness Energy problems Concentration problems Appetite problems Psychomotor activity problems: agitation or slowing Suicidal thoughts or behaviors

5. Types of Pediatric Depression Major Depression: sad-irritable moods or decreased interests, + 4 other symptoms, 2 weeks duration, impairing Minor Depressions: Dysthymia: 2+ symptoms, 1 year duration Adjustment disorder with depression: fewer sxs and shorter duration, response to stress Depressive disorder not otherwise specified Bipolar depression

6. Mania Mnemonic Markedly elevated or irritable moods and 3-4 GR:RAPID symptoms: Grandiosity Racing thoughts Reckless pleasure-seeking behavior Activity increased (goal-directed) Pressured speech Insomnia: decreased need for sleep Distractibility

7. Bipolar Disorders Must have had at least 1 manic or near- manic (hypomanic) episode Manic episodes must last 4+ days with markedly irritable or elated moods Depressed symptoms often last longer than manic symptoms

8. Bipolar Disorders in Children Rapid cycles Mixed episodes Often occur with psychotic symptoms Positive family history of bipolar disorder

9. Prevalence in Youths MDD: 2% in children, 8% in adolescents 20% by the end of adolescents have had at least one MDD episode Bipolar disorder: 1-2% 20-40% of patients with MDD become bipolar

10. Morbidity/Mortality of Unipolar and Bipolar Mood Disorders Bipolar more severe risk than unipolar Both typically recur, with worsening severity Both have serious long-term impact: Scholastic Interpersonal Occupational Substance abuse Legal problems Suicide

11. CAUSE# OF DEATHS Accidents6646 Homicide1899 Suicide1611 Cancer732 Heart Disease347 Congenital Anomalies255 Chronic Lower Respiratory Disease74 Stroke68 Influenza and Pneumonia66 Blood Poisoning57 Anderson & Smith 2003 1599 C.E14 Suicide: 3 rd Leading Cause of Death in Youths Ages 15-19 — U N I T E D S T A T E S, 2001 —

12. Environmental factors Traumatic exposure and other adverse life events Family conflicts Parental stress Peer problems School problems Are these a cause or an effect?

13. Heritability How much of the disorder is due to inherited, genetic factors (Nature) as opposed to environmental factors (Nurture)?

14. Genetic Factors Depressive disorders: 40% heritability 3X higher risk of depression in immediate family Bipolar disorders: 75% heritability 8X higher risk of bipolar disorder in immediate family 3X higher risk of depression in immediate family Family members of bipolar patients more likely to have unipolar than bipolar moods.

15. Pediatric Depression: Challenges of Assessment

16. Differential diagnoses: Anxiety Disorders Separation anxiety: child fearful anticipating separation from parent, clingy, school avoidant Social phobia: reluctant to interact with peers or perform because of fear of embarrassment

17. Differential diagnoses: Anxiety Disorders, continued Obsessive compulsive disorder: repetitive thoughts or behaviors, anxious/agitated when not able to do these, distressing and time consuming Panic disorder: intense panic attacks, brief and must sometimes occur without a specific trigger Generalized anxiety disorder: pervasive worries multiple things, physical complaints (insomnia, muscle tension, restlessness), irritability

18. Differential Diagnoses: Disruptive Disorders Irritability limited to specific situations involving authority figure Oppositional disorders: child angry, irritable & defiant with adults’ limit-setting, deliberately breaks rules, avoids accepting blame Conduct disorder: more severe DBD, lying, stealing, vandalism, aggression to animals or people

19. Differential Diagnosis: ADHD Problems in 1+ domains of symptoms Inattention: distractibility, disorganization, trouble listening Hyperactivity/impulsivity: restlessness, and the “butt-in-skies” Best discriminators: depressive cognitions > somatic/vegetative sxs

20. Comorbid Disorders Most mood disorders co-occur with some other disorders (comorbidity) Comorbid disorders occur first Complicate recognition of mood disorder Reduce effectiveness of treatments Worsen psychosocial outcomes

21. Assessment Strategies for Pediatric Depression

22. Diagnostic Work Up: History Review history of psychiatric symptoms Review medical problems Review family’s mental health history Assess child’s function at school, with peers, and at home Review stressors that may be contributing

23. Rating Scales Allow collection of data from multiple raters (child, parent, teachers) Screen for depressive symptoms and other diagnoses Help to monitor course of mood disorder and response to treatment

24. Rating Scales: General Scales Child Behavior Checklist, Teacher’s Report Form, Youth Self Report Child and Adolescent Symptoms Inventory, Adolescent Symptom Inventory Vanderbilt Parent and Teacher Rating Scales (see handout) Simple, easy to use and score Good screen for disruptive behaviors Spanish version available Available free on the web: http://devbehavpeds.ouhsc.edu/rokplay.asp

25. Vanderbilt Scales: Scoring Scoring guide on handout Count the number of symptoms rated 2 or 3 in various sections Symptoms clumped by disorders ADHD: #1-18 ODD: #19-26 CD: #27-40 Anxious/depressed: 41-47 Functional assessment section: #48-55, count the performance items rated 4 or 5

26. Rating Scales for Depression Beck Depression Inventory Children’s Depression Inventory Mood and Feelings Questionnaire (see handout) Parent- and child- versions, long and short forms Simple wording and structure Available free on web: http://devepi.mc.duke.eduhttp://devepi.mc.duke.edu Spanish version for parents developed by our group

27. Mood and Feelings Questionnaire: Scoring Useful to combine both parent and child ratings to see if there are at least 5 symptoms of depression reported as “True” Scores suggestive of possible major depression) Scores on long version > 24 Scores on short version > 7

28. Diagnostic Work Up: Mental Status Exam (MSE) Activity level Spontaneity Eye contact Affect Mood How do you feel talking to this kid?

29. MSE: Thought Content Self esteem Hopelessness Helplessness Delusions Hallucinations Suicidal thoughts or behaviors

30. Assessing for Suicide Ask about suicide, and document you did Use matter of fact questions: “Sometimes kids with these sorts of problems may feel like they’d be better off if they were dead. Do you ever feel that way?” “Have you ever thought about killing yourself?” “Have you thought of ways you could do it?” “What would make you more (or less) likely to do it?”

31. Assessing Suicide Risk Current mental health problems? Positive and negative environmental factors? Past history of suicide attempts? Does the child have current intentions to suicide? Lethality of methods considered? Availability of methods considered? Are there guns at home?

32. Treatment

33. Two Main Treatment Options Psychosocial Pharmacological

34. Psychosocial Treatments Supportive therapy Educate child and family, address contributing stressors, refer for assessment and treatment Cognitive behavioral therapy Depression result from cognitive distortions that can be corrected with training and practice Interpersonal therapy Uses the issues that come up in relationship with therapist to help child to cope more effectively

35. Antidepressants: Selective Serotoninergic Reuptake Inhibitors (SSRIs) Fluoxetine (Prozac): FDA-approved pedi dep, well tolerated, slow onset of effects, good for noncompliant patients Sertraline (Zoloft): approved for pedi OCD, wider dose range, some GI side effects and activation Citalopram (Celexa), Escitalopram (Lexapro): often well-tolerated and effective; faster acting? Fluvoxamine (Luvox): approved for pedi OCD, more drug interactions, less well tolerated Paroxetine (Paxil): No longer recommended in pediatric age range, withdrawal problems

36. Treatment of Adolescents with Depression Study (TADS) NIH-sponsored study of adolescents with major depression Compared fluoxetine, cognitive behavioral therapy, and combination treatments versus placebo Antidepressants were more effective than therapy, especially for severe depression Combination therapy more effective and safe

37. CDRS: Adjusted Means (ITT) TADS Team (2004), JAMA 292: 807-820

38. Non-SSRI Antidepressants: Bupropion (Wellbutrin): noradrenergic & dopaminergic, help pedi ADHD; risk of seizures Mirtazapine (Remeron): Useful for insomnia Duloxetine (Cymbalta): serotonin & noradrenergic effects Venlafaxine (Effexor): no longer recommended because of withdrawal symptoms Tricyclics: desipramine, imipramine, nortriptyline; helpful for insomnia and enuresis but not pedi depression; cardiovascular risks require ECG & plasma levels, fatal in overdoses

39. Depressed Child or Teen? At the University of Texas Health Science Center at San Antonio, we are conducting a clinical research study using an investigational medication bupropion for depression in adolescents ages 11-18 weighing at least 66lbs. Symptoms include: Sad or irritable mood Lack of concentration in school Loss of interest or pleasure Changes in appetite or weight Fatigue or loss of energy Feelings of worthlessness Feelings of hopelessness Sleep Problems Those who qualify will receive: Interview and Assessment Physical Exams Comprehensive Lab Analysis Medication Resource Referral Compensation available Continued care if applicable Call us at 210-562-5400 for more information

40. FDA “black box” warning for Antidepressants, October 2004 Higher suicidality in first weeks on antidepressants: 4% on antidepressant medication vs. 2% on placebo Applies to all antidepressants in all age groups Need close follow-up early for emerging suicidal thoughts, worsening mood or other intolerable side effects

41. C.E16.XX Why Use Antidepressants At All? US Epidemiological Studies, Ages 15-24 Rate per 100,000 Anderson 2002, CDC Wonder 2003, USDHEW 1956, Vital Statistics U.S. 1954–1978

42. 2-Years After Black Box… ~10% drop in antidepressant prescriptions to adolescents from 2004 to 2005 ~20% increase in adolescent suicide rates in the US (from 7.3 to 8.2 per 100K) Hamilton et al. (2007), Annual summary of vital statistics: 2005. Pediatrics 119(2):345-359

43. David Brent, MD: “The risk of emergent suicidality in children and adolescents receiving SSRIs is real-- but small.” Antidepressants help many more people than they hurt Brent DA (2004), N Engl J Medicine 351(16), p 1601

44. School Nurse’s Potential Role in Monitoring Weekly assessments, especially early in treatment for new or worsening symptoms: Suicidal thoughts or behaviors Insomnia Agitation or irritability Depressed moods or mania Communication with the prescribing physician if there are any concerns

45. Dr. Brent: “The Risk of Doing Nothing” “Families and clinicians must find the right balance between the risk of suicidality and [the] greater risk …that lies in doing nothing.” Brent DA (2004), N Engl J Medicine 351(16), p 1601

47. Summary Pediatric depression a potentially devastating problem, if undiagnosed or untreated We’ve reviewed risk factors, signs and symptoms of pediatric depression and suicide We’ve discussed strategies for assessment and treatment, especially in school setting

48. School Nurses’ Key Role Identification of children at risk for depression and/or suicide Offering education and support to children, parents, and staff at schools Helping families to weigh risks/benefits of various treatments and to follow through Helping clinicians to monitor children’s response to treatment

49. Potential Resources Web-pages for parents: www.aacap.org www.nami.org www.moodykids.org www.wpic.pitt.edu/research/CARENET/ Web pages for clinicians www.moodykids.org www.wpic.pitt.edu/research/CARENET/

50. Thanks!!!

51. Appendices: Vanderbilt Teacher’s Rating Scale Vanderbilt Parent’s Rating Scale Vanderbilt Parent’s Rating Scale– Spanish Version Child Mood and Feelings Questionnaire Parent Mood and Feelings Questionnaire Parent Mood and Feelings Questionnaire-- Spanish Version Study flyer for UTHSCSA Depression Trial