Guidelines for Adolescent Depression in Primary Care (GLAD-PC)

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Guidelines for Adolescent Depression in Primary
Care (GLAD-PC)

• Amy Cheung, MD
• Department of Psychiatry
• University of Toronto

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Outline

• Background
• GLAD PC development process
• GLAD PC Recommendations
• GLAD PC Toolkit
• Implementation plans

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GLAD-PC Steering Committee Liaisons

• Steering Committee
  Organizational Liaisons
• Boris Birmaher, MD John Campo, MD Darcy
  Gruttadaro (NAMI)
• Greg Clarke, PhD Dave Davis, MD Sue Bergeson
  (DBSA)
• Allen Dietrich, MD Graham Emslie, MD Mike Faenza
  (NMHA)
• Bernard Ewigman, MD Eric Fombonne, MD Eric
  Fombonne (CPA, CACAP)
• Sherry Glied, PhD, Kimberly Hoagwood, PhD Ben
  Vitiello (NIMH)
• Charles Homer, MD Danielle Laraque, MD James
  MacIntyre (AACAP)
• Miriam Kaufman, MD Kelly J. Kelleher, MD Bruce
  Waslick (AMA)
• Stanley Kutcher, MD Michael Malus, MD Deborah
  Ebner (SAM)
• James Perrin, MD Harold Pincus, MD Diane Sacks
  (CPS, AAP)
• Brenda Reiss-Brennan, RN Diane Sacks, MD Michael
  Malus (CCFP)
• Ruth E. K. Stein, MD Bruce Waslick, MD Angela
  Diaz (AAP)
• Angela Diaz, MD Judy Garber (APA)
• Jim Perrin (AAP)
• Kelly Kelleher (AAP)
• David Fassler (APA)
• Bernard Ewigman (AAFP)
• Stanford Friedman (SDBP)
• Sandra Spencer (FFCMH)

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GLAD-PC Support

• Project Team
• Peter S. Jensen, MD Amy Cheung, MD,
• Rachel Zuckerbrot, MD Kareem Ghalib, MD
• Anthony Levitt, MD
• Funders
• CSAT, SAMHSA Josiah Macy, Jr. Foundation
• NY Office of Mental Health Lowenstein Foundation
• University of Toronto AAP NY Chapters 1,23,
  District II
• NY Council CA Psychiatry NY Academy of Medicine
• Kellogg Foundation Civic Research Institute, Inc.
  

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Major Depressive Disorder in AdolescentsNeed to
Do Better in PC Settings

• Common in adolescence 8 lifetime prevalence
  (Cheung et al., in press)
• Significant burden of illness on patients and
  families
• High rates of depression in primary care settings
  (up to 28)
• 50 of youth with depression missed in primary
  care settings
• (Chang et al., 1988, Kramer Garralda,
  1998)
• Most providers think it is their responsibility
  to identify depression
• (Olson et al., 2001, Jensen, 2002)

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Major Depressive Disorder in AdolescentsNeed to
Do Better in PC Settings

• Most intend to screen for depression and
  suicide, but do it less often than other areas
  (sexual activity/birth control), only 15 and 17
  do it always (Halpern-Felsher et al, 2000
  Middleman et al., 1995)
• Shortage of mental health providers in both US
  and Canada
• Barriers to accessing services only 50 utilize
  services

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GLAD-PC Development Process

• Initial partnership between the Center for the
  Advancement of Childrens Mental Health, Columbia
  University and University of Toronto
• 16 focus groups primary care providers (n90),
  parents (n38), and youth (n13) (Salt Lake
  City, Orlando, New York City, Toronto, and
  Montreal)
• Questions included What tools/supports do you
  think is needed to manage adolescent depression
  in the primary care setting?, What
  tools/assistance would help you to manage MDD?,
  What would you want your doctor to do?

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GLAD-PC Development Process

• Systematic Evidence-Based Literature Reviews
• Screening and assessment measures in primary care
  settings
• Medication efficacy and safety
• Psychotherapy efficacy
• Efficacy of PCP-delivered counseling support
  strategies

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GLAD-PC Development Process

• Screening and assessment measures
• Large number of tools and scales available
• Efficacy of counseling support strategies
• Numerous studies but none examining depression
  care
• (i.e., enuresis, sleep problems)
• Evidence for effective PCP interventions in the
  pediatric primary care setting

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GLAD-PC Development Process

• Medication efficacy and safety
• FDA and Health Canada Warnings
• First-line SSRIs Fluoxetine (Prozac)
• Some suggestion of differences among SSRIs
• Monitoring schedule as outlined by FDA none
  provided by Health Canada

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GLAD-PC Development Process

• Consensus Survey
• Addressed common sense, practical, but critical
  problems not likely to be addressed by empirical
  literature
• Surveyed 78 depression experts
• 34 Items (220 questions)

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Please answer each question based on your opinion
of what should be the standard of care in the
primary care setting?

• 9 extremely appropriate treatment/strategy of
  choice, standard of care in primary care
• 7-8 usually appropriate a 1st line treatment
  one should often use in primary care
• 4-6 equivocal a 2nd line one should sometimes
  use in primary care (e.g., client/patient/family
  preference or if the 1st line treatment is
  ineffective, unavailable, or unsuitable)
• 2-3 usually inappropriate a treatment one
  should rarely use in primary care
• 1 extremely inappropriate a treatment/strategy
  one should never use in primary care
• DK dont know

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• An adolescent presents in primary care for an
  urgent care/sick visit with a medical chief
  complaint that is not in need of emergency care.
  Please rate the appropriateness of each of the
  following methods for routinely identifying
  emotional problems?

Youth-completed psychosocial problem checklist 1 2 3 4 5 6 7 8 9 DK
Youth-completed depression checklist 1 2 3 4 5 6 7 8 9 DK
Parent-completed general psychosocial questionnaire 1 2 3 4 5 6 7 8 9 DK
Parent-completed youth depression checklist 1 2 3 4 5 6 7 8 9 DK
Use of a screener 1 2 3 4 5 6 7 8 9 DK
Interview with youth asking general questions 1 2 3 4 5 6 7 8 9 DK
Interview with youth asking depression-specific questions 1 2 3 4 5 6 7 8 9 DK
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Consensus On Identification for Depression

Extremely

inappropriate

Extremely appropriate
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GLAD-PC Development Process

• Consensus Workshop
• Draft guidelines developed
• Progressive Iteration of Guidelines among experts
• Papers in progress
• Guideline papers Part I and II (GLAD-PC
  Steering Group, In Press)
• Screening/assessment review paper (Zuckerbrot et
  al., 2006)
• Antidepressant review paper (Cheung Emslie,
  2005)
• Consensus Survey paper (Cheung et al.)
• Review of benefits of PCPs support (Stein et al.,
  2006)

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GLAD-PC Development Process

• Preparatory steps
• Training for both mental health and primary
  care
• Liaison with mental health providers establish
  linkages with community resources
• Practice system changes

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GLAD-PC Guidelines Identification/Surveillance

• Recommendation I Patients with depression risk
  factors (such as history of previous episodes,
  family history, other psychiatric disorders,
  substance abuse, trauma, psychosocial adversity,
  etc.) should be identified and systematically moni
  tored over time for the development of a
  depressive disorder.

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How to recognize the moods of an Irish Setter
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GLAD-PC Guidelines Assessment/Diagnosis

• Recommendation I PC clinicians should evaluate
  for depression in high-risk adolescents as well
  as those who present with emotional problems as
  the chief complaint. Clinicians should assess
  for depressive symptoms based on diagnostic
  criteria established in the DSM IV or ICD 10 and
  should use standardized depression tools to aid
  in the assessment.
• Recommendation II Assessment for depression
  should include direct interviews with the
  patients and families/caregivers and should
  include the assessment of functional impairment
  in different domains and other existing
  psychiatric conditions.

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GLAD-PC Guidelines Initial Management

• Recommendation I PC clinicians should educate
  and counsel families and patients about
  depression and options for the management of the
  disorder. Clinicians should also discuss limits
  of confidentiality with the adolescent and
  family.
• Recommendation II PC clinicians should develop
  a treatment plan with patients and families and
  set specific treatment goals in key areas of
  functioning including home, peer, and school
  settings.

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GLAD-PC Guidelines Initial Management (cont.)

• Recommendation III The PC clinician should
  establish relevant links/collaboration with
  mental health resources in the community, which
  may include patients and families who have dealt
  with adolescent depression and are willing to
  serve as resources to other affected adolescents
  and their family members.
• Recommendation IV All management must include
  the establishment of a safety plan, an emergency
  communication mechanism should the patient
  deteriorate, become actively suicidal or
  dangerous to others, or experience an acute
  crisis associated with psychosocial stressors
  especially during period of initial treatment
  when safety concerns are highest.

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GLAD-PC Guidelines Treatment

• Recommendation I After initial diagnosis, in
  cases of mild depression, clinicians should
  consider a period of active support and
  monitoring before starting other evidence-based
  treatment.
• Recommendation II If a PC clinician identifies
  an adolescent with moderate or severe depression
  or complicating factors/conditions such as
  co-existing substance abuse or psychosis,
  consultation with a mental health specialist is
  recommended. Appropriate roles and
  responsibilities for ongoing management by the PC
  and mental health clinicians should be
  negotiated. The patient and family should be
  consulted and approve the roles of the PC and
  mental health professionals.

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GLAD-PC Guidelines Treatment (cont.)

• Recommendation III PC clinicians should
  recommend scientifically-tested and proven
  treatments (i.e., psychotherapies such as
  cognitive behavioral therapy or interpersonal
  therapy, and/or antidepressant treatment such as
  SSRIs) whenever possible and appropriate to
  achieve the goals of the treatment plan.
• Recommendation IV PC clinicians should monitor
  for the emergence of adverse events during
  antidepressant treatment (SSRIs).

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GLAD-PC Guidelines Ongoing Management

• Recommendation I Systematic and regular
  tracking of goals and outcomes from treatment
  should be performed including assessment of
  depressive symptoms and functioning in several
  key domains home, school, and peer settings.
• Recommendation II Diagnosis and initial
  treatment should be reassessed if no improvement
  is noted after 6-8 weeks of treatment. Mental
  health consultation should be considered.

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GLAD-PC Guidelines Ongoing Management (cont.)

• Recommendation III For patients achieving only
  partial improvement after PC diagnostic and
  therapeutic approaches have been exhausted
  (including exploration of poor adherence,
  co-morbid disorders, and ongoing conflicts or
  abuse), a mental health consultation should be
  considered.
• Recommendation IV PC clinicians should
  actively support depressed adolescents referred
  to mental health to ensure adequate management.
  PC clinicians may also consider sharing care with
  mental health services where possible.
  Appropriate roles and responsibilities, and
  co-ordination of care, should be negotiated
  between the PC clinician and the mental health
  specialist.

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Thats good. Touch the guidelines, the
guidelines are your friend.
Getting health professionals to use guidelines
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GLAD-PC Toolkit

• Screening and Assessment
• Primary Care Provider Fact Sheet
• Screening/Assessment Tools
• Beck Depression Inventory
• Patient Problems Questionnaire (PHQ-A)
• Columbia DISC Depression Scale
• Kutcher Adolescent Depression Scale

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GLAD-PC Toolkit

• Treatment
• Treatment Choices
• Psychotherapy
• Medication
• Treatment Guidelines
• Treatment Management and Follow-up
• Flowsheet
• Guide to referrals
• Pocket Guide, Stickers, etc.

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GLAD-PC Toolkit

• Psychoeducation Materials/Provider
• What to tell parents about depression?
• Psychoeducation Materials for Children/Adolescents
  
• Self-Care Success
• Blue Daze Booklet for Youth
• Psychoeducation Materials for Parents
• Depression Fact Sheet
• FAQs about Antidepressants
• Family Support Action Plan (NAMI, DBSA)
• Other Patient and Family Handouts
• Facts on Psychological Counseling
• Communication Tools Between Providers

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GLAD-PC Toolkit

• Other areas to be added
• Organization/getting ready checklist
• Working with schools and teachers
• Working with community resources

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GLAD-PC Guidelines Issues for Discussion

• Should these guidelines be universally deployed?
• Age 10-21
• PCP readiness, willingness
• Mental health services availability and family
  acceptance of referral
• System fixes
• System and practice redesign
• Medical records and technological innovations
• New collaborative models
• Guidelines alone insufficient
• Tools and testing required

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GLAD-PC Guidelines Implementation Plans

• Toolkit development
• Pilot testing with family medicine and pediatrics
• Modification based on feedback
• Slight variations based on different clinician
  groups, and practice models
• On-going collaboration with Canadian
  Collaborative Mental Health Initiative

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GLAD-PC Guidelines Implementation Plans

• Testing of collaborative care models
• Shared care
• On-site mental health support
• Telephone consultation
• Initial studies to examine feasibility and
  qualitative data on models
• Larger randomized controlled trial to examine
  changes in patient outcomes