1. Managing Adolescent Depression in Primary Care

2. Copyright © The REACH Institute. All rights reserved. Hidden Slide: Time Table Total time: 60 minutes Learning Objectives: 2 minutes Lecture: 9 minutes Expert Panel: 20 minutes Table Role Plays: 20 minutes Review & Summarize Table Experiences: 5 minutes Wrap-up: 4 minutes Unit H: Managing Depression

3. Copyright © The REACH Institute. All rights reserved. Learning Objectives Identify treatment components of the AAP- approved Guidelines for Adolescent Depression – Primary Care (GLAD-PC) Select treatment plans that match MDD severity Summarize evidence-based treatments for adolescent MDD Describe clinical recommendations when selecting and using SSRI’s with adolescents Review safety planning, assessing suicide risk, and discussing the FDA boxed warning

4. Copyright © The REACH Institute. All rights reserved. Agenda Review treatment of adolescent depression in PCP settings using the GLAD-PC treatment recommendations Review and apply GLAD-PC flow chart for adolescent MDD treatment to Jennifer and David Peer practice: 1. Safety planning 2. Suicide risk assessment 3. Discussing Boxed Warning with parents Expert panel discussion on treating pediatric depression

5. Copyright © The REACH Institute. All rights reserved. GLAD-PC Guidelines: Initial Management Educate and counsel families and patients about depression and treatment options (Pages 102- 110). Develop a treatment plan with patients and families with specific goals in key areas of functioning including home, peer, and school. Establish collaboration with mental health resources in the community and with other patients and families. See www.glad-pc.org for entire GLAD-PC toolkit

6. Copyright © The REACH Institute. All rights reserved. GLAD-PC Guidelines: Treatment Categorize current depressive episodes into one of three levels based on assessment tools and your clinical judgment (See p. 53 for definition and 57-64 for tools) –Mild depression –Moderate depression –Severe depression See www.glad-pc.org for entire GLAD-PC toolkit

7. Copyright © The REACH Institute. All rights reserved. GLAD-PC Guidelines (See next slide in Participant Book) Mild (Specific info: patient education / referral / follow-up) –Consider a period of active support and monitoring before starting other evidence-based treatment. Moderate –Consider starting an SSRI or an Evidence Based Psychotherapy (EBP) Severe –SSRI’s and EBP are optimal treatment Complicating factors/conditions (e.g. co-existing substance use/abuse, self-injury, suicidal ideation (SI)) –Consider MH referral or hospitalization

8. Copyright © The REACH Institute. All rights reserved. GLAD-PC (Guidelines for Adolescent Depression – Primary Care), p. 16 See www.GLADPC.org for complete toolkit, 1-151 pgswww.GLADPC.org See WkBk H 1.0

9. DRAFT Hidden Slide: Presenter asks participants to find the flow sheet (H 1.1), which is with the slides, to quickly review the treatment recommenda- tions (have previous slide up and go through Jennifer and David). Copyright ©2014 The REACH Institute. All rights reserved.

10. Copyright © The REACH Institute. All rights reserved. Hidden Slide Presenter: Discuss Jennifer’s mild depression management and watchful waiting. Discuss David’s moderate depression and referral to therapy. Unit P: Depression Primary Care Setting

11. Copyright © The REACH Institute. All rights reserved. GLAD-PC (Guidelines for Adolescent Depression – Primary Care), p. 17 See www.GLADPC.org for complete toolkit, 1-151 pgswww.GLADPC.org a Psychoeducation, supportive counseling, facilitate parental & patient self-management, refer for peer support and regular monitoring of depressive symptoms and suicidality. b Negotiate roles/ responsibilities between primary care and mental health, and designate case co-ordination responsibilities. Continue to monitor in primary care after referral. Maintain contact with MH c Professionals should monitor for changes in symptoms and emergence of adverse events such as increased suicidal ideation, agitation or induction of mania. For monitoring guidelines please refer to guidelines/toolkit. See WkBk H 1.1

12. Copyright © The REACH Institute. All rights reserved. Evidence Based Psychotherapies for Depression Cognitive Behavioral Therapy (CBT) Interpersonal psychotherapy- some evidence supporting role in pediatric depression

13. Copyright © The REACH Institute. All rights reserved. What about the antidepressant medications?

14. Copyright © The REACH Institute. All rights reserved. Treatments for Depression Pharmacotherapy Fluoxetine (Prozac)--FDA approved for pediatric patients 8-18 years of age Escitalopram (Lexapro)--FDA approved for adolescents 12-17 years of age Psychotherapy: Cognitive Behavioral Therapy (CBT) Interpersonal psychotherapy- Some evidence supporting role in pediatric depression ECT Light Therapy TMS (transcranial magnetic stimulation) – Preliminary study

15. Copyright © The REACH Institute. All rights reserved. Antidepressants—Mechanism SSRIs selectively block the reuptake of 5-HT (first-line pharmacotherapy) TCAs block the reuptake of 5-HT and/or norepinephrine MAOIs block monoamine oxidase (MAO), thereby blocking metabolism and increasing neurotransmitter availability in the synapse

16. Copyright © The REACH Institute. All rights reserved. MEDICATIONDrugPlaceboP value Fluoxetine (Prozac) (March ’04)* 56%33%0.02 Fluoxetine (Prozac) (Emslie ’97) 52%37%0.03 Fluoxetine (Prozac) (Emslie ’02) 61%35%0.001 Paroxetine (Paxil) (Keller ’01)** 66%48%0.02 Paroxetine (Paxil) (Unpublished)69%57%NS Paroxetine (Paxil) (Unpublished)65%46%0.005 Citalopram (Celexa) (Wagner ’04) 47%45%NS Sertraline (Zoloft) (Wagner ’03) 63%53%0.05 Escitalopram (Cipralex) (Emslie ’09)64%53%0.03 *Fluoxetine alone compared to placebo **Paroxetine compared to placebo Response Rates in RCT’s of Antidepressants (for depression) based on CGI (Clinical Global Impression)

17. Copyright © The REACH Institute. All rights reserved. Treatment Tactics—Depression Initiation –Minimal or no response: total trial should not exceed 4-8 weeks –Partial response: trial up to 12 weeks –Monitoring: q1-2 weeks initially –Initiate 2 nd SSRI for non-response to first agent (x-taper) Continuation Phase –Continue medications 6-9 months after symptom remission –When discontinuing, taper no more than 25% per week –Monitor q 2-4 months as relapse most likely in first 8 months 60-70% recurrence of MDD in adulthood Maintenance: 3 years – lifetime (no data)

18. Copyright © The REACH Institute. All rights reserved. Nuts and Bolts of SSRIs for Depression How to choose an SSRI –Evidence –Drug-drug interactions –Side effect profile –Patient preference –Previous good result with family member Starting and titrating –Start low, go slow (refer to SSRI table for starting dose) –Increase to target dose * in 1-4 weeks Write prescription that makes increase to target dose See patient back after 1-4 weeks and increase dose –Allow for trial of 6-8 weeks Discontinuation Cross taper * probable, effective dose

19. Copyright © The REACH Institute. All rights reserved. Adverse events in SSRIs and Non-SSRIs Common Nausea Diarrhea Headache Feeling tired Nervousness Agitation Sleep difficulties Dry mouth Sweating Tremors Feeling dizzy Appetite changes Rare Increased bleeding Increased bruising Sexual side effects Vivid or strange dreams Bruxism Increased risk of sunburn Hair loss Difficulty breathing Serotonin syndrome New onset suicidal ideation? Less Common Rashes Itchiness Swelling Sexual disturbance Problems concentrating Blurry vision Increased yawning Constipation Changes in patterns of passing urine Akathisia

20. Copyright © The REACH Institute. All rights reserved. The FDA Boxed Warning “the Black Box” Applies to all medications with FDA indication for depression - Antidepressants (SSRIs & non-SSRI’s) Suicidality –Increased risk of suicidality in children, adolescents and young adults w/ major depressive or other psychiatric disorders especially during the first months of treatment with antidepressants vs. placebo. –Weigh risk vs. benefit: In short-term studies of antidepressants vs. placebo, suicidality risk was not increased in patients >24 y/o, and risk decreased in patients >65 y/o. –Observe all pts for clinical worsening, suicidality, or unusual behavior changes

21. Copyright © The REACH Institute. All rights reserved. Residual Symptoms & Relapse Patients with residual symptoms have an increased risk of relapse Partial remission is related to poor outcome in both medication and CBT trials Increased risk for relapse (77% vs. 48%) by 36 months if SSRI is discontinued – Emslie et al., 2008

22. Copyright © The REACH Institute. All rights reserved. SSRIs for Depression in Adolescents Copyright ©2014 The REACH Institute. All rights reserved.

23. Copyright © The REACH Institute. All rights reserved. GLAD-PC Guidelines: Ongoing Management Perform systematic and regular tracking of goals and outcomes from treatment, including assessment of depressive symptoms and functioning in several key domains: home, school, and peer settings. Reassess diagnosis and initial treatment if no improvement is noted after 6-8 weeks of treatment. Mental health consultation should be considered. Ask suicidality questions and monitor warning signs.

24. Copyright © The REACH Institute. All rights reserved. Hidden Slide: Transition Back to the Case of David Presenter: Update David’s case - He doesn’t want therapy, but is willing to start medication. The doctor agrees with David, and decides to start an SSRI. Peer practice discussing Black Box with parent and in safety planning. Volunteer and David’s parent (see Faculty Agenda) demonstrate the Black Box warning discussion and starting an SSRI for group.

25. Copyright © The REACH Institute. All rights reserved. Peer Practice: Suicide Risk and Safety Planning Task One: Read the Unit F workbook pages on suicide risk assessment and preventing suicide (F 1.1 –1.4). Task Two: Discuss the boxed warning and safety planning with parent (F1.1-1.3). –In pairs and using the Boxed Warning and Ways to Prevent Suicide handouts, discuss with the parent how to safety-proof the home and monitor suicide risk. Task Three: Volunteer to role play Task 2 with a parent in front of the entire group

26. Copyright © The REACH Institute. All rights reserved. Treatment Summary Involve and educate parents & youth about MDD. See www.parentsmedguide.org for parent handouts Mild depression needs “active monitoring” & support Moderate to severe depression may need combined treatment (SSRI plus EBP) Any child on medication needs to be monitored closely. Medication can be an important component of treatment, but medication alone is rarely the answer. Your active support & monitoring, +/- an EBP (CBT or IPT) always essential.

27. Copyright © The REACH Institute. All rights reserved. Hidden Slide: Transition to the Expert Panel Discussion The presenter invites the expert panel to the front of the room. The panelists read and answer questions from the white index cards collected during the depression units. When index card questions are exhausted, panelists can take questions verbally.

28. Copyright © The REACH Institute. All rights reserved. Ask the Experts: Treatment of Child and Adolescent Depression Ask the Experts: Treatment of Child and Adolescent Depression

29. Copyright © The REACH Institute. All rights reserved. REMINDER: REMINDER: Please fill out Unit H evaluation

30. Copyright © The REACH Institute. All rights reserved. RESOURCE SLIDE Why CBT? Acute CBT Trials in Youth w/MDD Effect size:.34; Weisz et al., 2006

31. Copyright © The REACH Institute. All rights reserved. RESOURCE SLIDE Meta-Analysis of SSRI RCTs 27 major depressive disorder (MDD) trials Pooled risk differences (benefit vs. risk) favored antidepressants vs. PBO for MDD –Effect size=0.25 Efficacy moderated by: Age, Duration of MDD, and # of sites in the RCT Children < 12 y.o.: only fluoxetine showed benefit over PBO Bridge JA, et al. JAMA 2007;297:1683-1696

32. Copyright © The REACH Institute. All rights reserved. RESOURCE SLIDE TADS CDRS Findings: (Children’s Depression Rating Scale) T A D S

33. Copyright © The REACH Institute. All rights reserved. RESOURCE SLIDE Discontinuation symptoms Flulike symptoms (e.g., headache, diarrhea, nausea, vomiting, chills, dizziness, fatigue) may occur when suddenly stopping SSRI medications, and this is more common in agents with short half-lives. SSRIs also have a higher margin of safety in overdoses compared to TCAs and MAOIs. Deaths have been reported with large ingestions of SSRIs (either alone or in combination with other medications).

34. Copyright © The REACH Institute. All rights reserved. Emslie Fluox Emslie et al. Am J Psychiatry Feb 2008 102 Adolescents –Mean age 11.8+2.8 yr. –MDD Responders Fluoxetine X 12 Weeks CGI-S of 1 or 2 & CDRS- R < 28 –Randomized Fluoxetine Placebo –Relapse Score > 40 CDRS X 2 Weeks Survival Curve Time to Relapse RESOURCE SLIDE

35. Copyright © The REACH Institute. All rights reserved. RESOURCE SLIDE Continuation Treatment

36. Copyright © The REACH Institute. All rights reserved. Resource Slide: GLAD-PC Toolkit Psychoeducation Materials/Provider –What to tell parents about depression? Psychoeducation Materials for Children/Adolescents –Self-Care Success Psychoeducation Materials for Parents –Depression Fact Sheet –FAQs about Antidepressants –Family Support Action Plan (NAMI, DBSA) (long version) Other Patient and Family Handouts –Facts on Psychological Counseling –Communication Tools Between Providers Suicide –Suicide & SSRIs –Suicide prevention tips www.glad-pc.org Copyright ©2014 The REACH Institute. All rights reserved.