Adolescent Depression: A Brief and Practical Update

1
Adolescent Depression A Brief and Practical
Update

• Elizabeth Baerg Hall,
• M.D., CCFP, FRCPC
• Mood and Anxiety Disorders Clinic,
• BC Childrens Hospital, Vancouver

2
Objectives

• Review the approach to depressed adolescents
  presenting in primary care
• Briefly sort through current medication
  controversies
• Provide an overview of Interpersonal Therapy for
  Adolescents (IPT-A)
• Describe an application of these principles for
  primary care

3
Objectives

• Review the approach to depressed adolescents
  presenting in primary care

4
Adolescent Depression

• Prevalence 5-8
• Cumulative Risk 20-25 by 18
• Recovery Rate 50-90
• Risk of Recurrence after first episode in
  adolescence 70 within 5 years
• Duration 3 to 9 months
• Subjective state of depressed mood is very common

5
Comorbidity with MDD

• 80-95 of children (60-90 adults)
• Dysthymia 30
• Anxiety Disorders 33 (Separation Anxiety
  Disorder most common)
• Conduct Disorder 15
• Other LD, PTSD, Substance Abuse

6
Diagnostic Issues

• SIGECAPS
• Mood Description Irritability
• Other Risk Behaviours
• Suicide
• Self Harm
• Substance Abuse
• Sexuality
• Physical Examination and Bloodwork

7
Diagnostic Issues

• Cross-sectional vs. Longitudinal diagnosis
• Collateral
• Mood Rating 1-10
• Beck Depression Inventory

8
Managing Depressed Adolescents

• After Diagnosis is Established
• Establish Treatment Plan
• Psychoeducation
• Self Care Strategies
• Refer for therapy
• Consider Medication
• See Regularly
• Cast the Net
• Establish Supports (Family School)

9
Managing Depressed Adolescents Suicidality

• Safety Plan Promises Not To Engage In Suicidal
  Behaviour Or Agreement To Contact If Recurrence
• Inform About Local 24 Hour Resources
• Review Precipitants Work Out Truce With
  Conflicting Parties
• Promote Hopefulness
• Address Impulsivity/ Risk Factors
• Substance Use
• Unprotected Sex
• Bingeing
• Clear the Environment - Safety
• Supports

10
Objectives

• Briefly sort through current medication
  controversies

11
Medication Considerations

• Black Box Warnings ? Suicidality But Not
  Completed Suicides (RR 21)
• Studies To Date
• High Placebo Response Rate (60-70)
• Published/Unpublished Studies
• Risk/Benefit Ratio for Fluoxetine is Small
• No Improvement On Self, Parent Or Global
  Functional Ratings
• Improvement vs. Remission Rate
• Improvements Probably Due to Anxiolytic Effect Of
  Drug

12
Whats New

• TADS Treatment for Adolescents With Depression
  Study (2004)
• Fluoxetine CBT (Cognitive Behavioural Therapy),
  Fluoxetine alone, CBT alone, and placebo
• N 439
• Moderate to severe depression
• CBT alone and CBT fluoxetine were unblinded

13
Whats New TADS Adverse Events

• Harm Related
• Harm to Self including cutting, worsening of
  suicidal ideation, suicide attempt or Harm to
  Others
• Limited evidence for ? in adverse events in both
  groups (fluoxetine and fluoxetine CBT groups
  vs. placebo)

14
Whats New TADS Outcomes

• CGI (Clinical Global Improvement) Clinician
  Rated Blind
• CDRS-R (Childrens Depression Rating Scale)
• Improvement or Remission?
• improved CDRS-R scores were still well within
  moderate depression range

15
Whats New TADS Conclusions

• TADS team suggests combo is best for moderate to
  severe depression (fluoxetine and CBT)
• This is controversial because of
• Study design (blinding)
• Improvement not remission as outcome variables
• Suicide and Harm-related side effects (include
  fluoxetine)
• Good to have information on moderate to severe
  depression in adolescents

16
Medication Considerations The Clear Advice

• If you treat with meds approximately 80 will
  improve
• 60-70 is due to combinations of
• Placebo effect
• Supportive interventions
• Expectations of patient
• Your expectations of improvement

17
Medication Considerations

• Indications for Medications
• Severity of depression
• Especially sleep, eating, impaired function
• Persistent symptoms despite initiation of
  therapeutic program
• Comorbid Conditions
• E.g.. Anxiety disorder
• Consider Risk/Benefit Ratio

18
Medication Considerations

• When you must use meds
• Fluoxetine first in family practice
• Prescribe therapy as well if possible
• Monitor closely
• Weekly x 4 weeks then biweekly to 3 months
• Side Effects
• Amotivational syndrome
• Misinterpreting the side effects of meds as
  worsening symptoms of depression
• SSRI monitoring sheet www.cpsbc.bc.ca/physician/do
  cuments/ssri.htm

19
Medication Considerations The Six Ns

• Never on the First Visit
• Nothing Old -TCAs, paroxetine
• Nothing Fancy - venlafaxine
• Nothing New - mirtazepine
• Not Alone - Also prescribe a psychotherapy
  intervention
• No Lone Guns - Follow local patterns of practice

20
Everything Has Changed and Nothing Has Changed

• Its A Big Deal To Give Medications To A
  Depressed Adolescent
• Consider The Importance Of The Message You Give
  By Prescribing
• Consider Substituting Skilled Psychoeducation For
  The Medication Intervention In Early Stages

21
(No Transcript)
22
CPA Guidelines

• When meds are used
• Clear discussion of risks and benefits
• Monitor for suicidality
• (once weekly contact in person or by phone for
  4/52)

23
NICE Guidelines Royal College of Psychiatrists
2005 (www.nice.org.uk)

• No meds for initial treatment of mild depression
• Antidepressants only in combination with
  concurrent psychological therapy
• Psychiatric Assessment prior to starting meds
• Fluoxetine first close monitoring

24
Objectives

• Provide an overview of Interpersonal Therapy for
  Adolescents (IPT-A)

25
Interpersonal Psychotherapy

• Gerald Klerman, M.D. and Myrna Weissman, Ph.D.
• Time Limited (16-20)
• Originally for Adult Outpatients
• Depressed
• Not Bipolar
• Not Psychotic

26
Principles of IPT

• Depression occurs in the context of relationships
  that can trigger or exacerbate the depression
• Targeting the symptoms and focusing on
• Understanding the relationship between
  interpersonal events and mood
• Improving current relationships using a variety
  of targeted strategies and skills
• Results in better interpersonal efficacy and
  recovery from the depression

27
Depression Circle

• Depression Relationships

28
Goals of IPT-A

• Symptom relief from depression
• Improved interpersonal functioning
• Decreased intensity and frequency of maladaptive
  patterns
• Better utilization of existing supports
• Resolution of problem area

29
IPT-A Key Components

• Time Limited (12 - 15 weeks)
• Psychoeducation
• Interpersonal Inventory
• Treatment Approach Based on Problem Area
• Increased Awareness of Mood (and Relationship of
  Mood to Interpersonal Events)
• Interpersonally-Oriented Skills Component
• Parent Sessions
• Work With School as Necessary

30
Psychoeducation

• You have depression
• Limited Sick Role
• Expect 90 improvement
• Instill Hope educate about prognosis
• Understand the importance of the clearly
  presented diagnosis for adolescent and family

31
Limited Sick Role

• Give the notion of having a medical problem that
  will improve, e.g. broken leg
• Draw parallels with how this affects their day to
  day functioning, e. g. pain, cant do phys. ed.
  (same as depression symptoms)
• OK to revise performance expectations while
  depressed
• Encourage parents to be less critical of
  performance and more supportive of participation

32
IPT-A Key Components Problem Areas

• Grief
• Role Transition
• Role Disputes
• Interpersonal Deficits

33

• Precipitating
• Event
• Dad in hospital

• Relationships
• Tumultuous On and Off
• Relationship with GF
• Inability to reconnect with
• friends

• Feelings
• Overwhelmed
• Responsible
• Irritable

• Feelings
• Morose about loss
• of GF
• Hurt
• More Isolated

• Relationships
• Arguing with Brother
• Breaks up with GF
• precipitously

Depression Symptoms Insomnia Poor
Concentration Weight Loss

• Feelings
• Sad
• Isolated

• Relationships
• Fights at Hockey
• Isolates from Friends

34
Closeness Circle SK
Trish
Joel
Brother
Grandpa Grandma
Tyler
Me
KC
Kelly
Mom
GF-Jay
Ken
Sylvie
Cindy
Kevin
Amanda
Candy
Oma Opa
Dad
Myles
35
Precipitating Event
Feelings
Relationships
Relationships
Feelings
Depression Symptoms
Depression Circle
36
IPT-A Key Components Middle Phase

• Identify needed skills
• Work on real life communication, negotiation,
  decision making
• Link mood and events as impetus for change

37
Techniques in IPT-A

• Psychoeducation
• Exploration And Expression Of Feelings
• Clarification Of Expectations And Hopes For
  Relationships (What Do I Want?)
• Communication Analysis
• Role Playing
• Decision Analysis/Problem-solving
• Work At Home

38
Anti-depressant Skills

• Communication
• Empathy

39
Communication Skills Talking Tips

• AIM FOR GOOD TIMING
• Make appointments with people you need to talk
  to.
• Avoid times when those people are
  tired/upset/etc.
• Example Mom, I know you are pretty tired from
  working so hard today. Theres something I want
  to talk to you about. Can we talk on Saturday
  after we clean?
• Strike when the iron is COLD even if you have to
  suck it in a little when the iron is HOT.

40
Communication Skills Talking Tips

• GIVE TO GET
• START WITH A POSITIVE STATEMENT THAT SHOWS YOU
  UNDERSTAND HOW THEY FEEL
• Dad, I know how much you love me and want
  nothing to ever happen to me, but
• Mom, I know you worked really hard today and you
  are probably pretty tired. You probably dont
  want me to ask you anything right now butcan I
  use the phone for 20 minutes?

41
Communication Skills Talking Tips

• USE I STATEMENTS
• Say how YOU feel about what they do.
• Example I feel like you dont trust ME when
  you want me to be home by 7 pm on Saturday
  nights. Then I feel sad and angry.
• People cannot read your mind no matter how it
  seems. PUT IT IN WORDS!
• Start with I
• Example Mom, I feel sad when you Dad, I
  feel you dont trust me

42
Anti-depressant Skills

• Problem Solving
• Decision Making

43
Problem Solving

• HAVE A FEW SOLUTIONS IN MIND
• If you want to work something out, do a little
  prep work! Come up with 3 or 4 compromises to
  whatever you are arguing about.
• Dad, I know you how much you worry about me when
  I go out after 7 pm on Saturday nights. But I
  feel really angry when you call me every five
  minutes on my cell phone. I love you, and I dont
  want to feel this way about you.

44
Problem Solving

• Solutions 1. How about if I call you every hour
  (every two hours? Every half hour?)
• 2. How about if I let you speak with my friends
  parents when I go to her house, and that I call
  you if I leave there so you know where I am?
• 3. How about if I call you when we get to the
  movies, and then again when we leave so you will
  know when to expect me. I promise I will call you
  immediately if we change plans.

45
Problem Solving

• DONT GIVE UP!
• Remember, it takes a LONG time to teach someone
  to do something differently. Your
  parents/guardians are used to handling things the
  way they have for YEARS. KEEP TRYING

46
Anti-depressant Skills

• GF
• Strike While The Iron Is Cold
• Cant Change People
• The Warrior Prince
• The Smashed Cell Phone
• Keep The Competition On The Rink
• Friends Count
• Family
• No One Wants You To Be Depressed
• Join Forces To Solve The Problem
• Cant Change People

47
Objectives

• Describe an application of IPT-A principles for
  primary care

48
Therapeutic Relationship

• Acknowledge the Importance of Your Role With
  Patient
• Collaborator/Coach Model
• Transparency
• Confidentiality
• Nonjudgmental
• Realistic Assessment of Prognosis
• Refer But Follow
• Consider Your Expectations of Patient

49
Preparation for Psychotherapy

• Pick a manageable problem area
• Temporally related to the depression
• Do a Depression Circle
• Encourage Introspection
• Get a Journal
• Weekly Focus
• What has been bothering me? Where am I stuck?
• Build on existing strengths

50
Precipitating Event
Feelings
Relationships
Relationships
Feelings
Depression Symptoms
Depression Circle
51
Antidepressant Strategies Self Care (NICE
Guidelines 2005)

• Exercise
• Develop Self Efficacy
• Group Exercise increases social contacts
• Physiologic Benefits
• Sleep Regulation
• Consider Light Box
• Timing of Exercise
• Relaxation Skills

52
Antidepressant Strategies Self Care

• Diet
• Omega 3, Selenium, Magnesium
• Internet Resources
• Dealing With Depression
• Bilsker D., Gilbert M., Worling D., Garland E.J.
• http//www.mcf.gov.bc.ca/mental_health/current_ini
  tiatives.htm

53
Summary Family Medicine Approach to IPT-A

• Recognition of burden of illness You have
  depression. This has affected your friendships,
  family and school relationships.
• You can change this instill hope and agency
• Here and now focus
• Collaborative exploration between patient and
  practitioner How did that affect your mood?
  What might you do to change it?
• Actively reinforce small steps toward improvement
• Generalize positive problem-solving/communication
  strategies to other situations

54
IPT-A Contraindications

• Psychotic Symptoms
• Comorbid Substance Abuse - Need To Treat First
• Active Suicidality
• Another Primary Disorder Such As Eating Disorder,
  Obsessive-compulsive Disorder
• Significant Expressive Or Receptive Language
  Disorder
• Under The Age Of 12 Years - No History Of Use
  With This Age Group

55
IPT-A Knowledge Translation Project

• Columbia University, University of British
  Columbia, University of Toronto
• Ministry of Child and Family Development,
  Government of British Columbia
• Training of Community Mental Health Therapists in
  IPT-A

56
Objectives

• Review The Approach To Depressed Adolescents
  Presenting In Primary Care
• Briefly Sort Through Current Medication
  Controversies
• Provide An Overview Of Interpersonal Therapy For
  Adolescents (IPT-A)
• Describe An Application Of These Principles For
  Primary Care

57
References

• March, JS, et al. Fluoxetine, Cognitive-Behaviora
  l Therapy and Their Combination for Adolescents
  With Depression Treatment for Adolescents With
  Depression Study (TADS) Randomized Controlled
  Trial, JAMA 2927, 2004, pp 807-820.
• Garland, EJ. Managing Adolescent Depression in
  the New Reality, BCMJ 4610, 2004, pp 516-521.
• Weissman, M.M., Markowitz, J.C., Klerman, J.L.
  (2000). Comprehensive Guide to Interpersonal
  Pyschotherapy. New York Basic Books.

58
Resources

• Mufson, L., Dorta, K.P., Moreau, D., Weissman, M.
  (2004). Interpersonal Psychotherapy for Depressed
  Adolescents. New York Guilford Press.
• International Society of IPTwww.interpersonalpsyc
  hotherapy.org
• Garland EJ. Selective Serotonin Reuptake
  Inhibitors in Children and Adolescents
  Information and Medication Monitoring Form (BC
  College of Physicians and Surgeons Website)
  www.cpsbc.bc.ca/physician/documents/ssri.htm
• Bilsker D., Gilbert M., Worling D., Garland E.J.,
  Dealing With Depression http//www.mcf.gov.bc.ca/m
  ental_health/current_initiatives.htm

59

• Elizabeth Baerg Hall (ehall_at_cw.bc.ca),
• BC Childrens Hospital, 604-875-2082