Even prior to Covid, the prevalence of Major Depression Disorder (MDD) in adolescents was reported as 6%, with an additional 5-10% of teens presenting with sub-syndromal symptoms of depression. There was and remains a 2:1 female:male ratio for the condition in adolescents. Teens frequently don’t necessarily present with the typical DSM criteria for MDD as defined for adults.  Common depressive symptoms in adolescents include: irritability (as opposed to reporting sad mood), mood lability, being quick to get angry, low self-esteem, hopelessness, sleep disturbance, appetite disturbance, suicidal thoughts and attempts, isolation, loss of interest in activities they previously enjoyed, and impairment in academic and social functioning. They sometimes report new-onset difficulty with sustaining attention and being academically motivated, which doesn’t fit well with a diagnosis of Attention Deficit Hyperactivity Disorder – inattentive subtype because the symptoms were not present at a younger age. A depressive episode can be triggered by a significant psychosocial stressor, but, if the symptoms last longer than 2 weeks, then it raises the suspicion of being more than an adjustment to a stressor unless the stressor is ongoing as may occur in situations of severe family dysfunction or cases of maltreatment.

Depression is highly co-morbid with other psychiatric disorders, like anxiety disorders, substance abuse disorders and disruptive behavior disorders. If an adolescent is presenting with depressive symptoms, it is important to take a careful history of bipolar symptoms, including current and past manic, hypomanic or psychotic symptoms, family history of bipolar disorders, and history of medication-induced manic or hypomanic symptoms. Twenty percent of children and adolescents with depression are reported to go on to develop some form of bipolar disorder as adults as evident in that many adults diagnosed with bipolar disorder report they first experienced depressive symptoms starting in childhood or adolescence without evidence of periods of mood elevation.

Since 2014, the American Academy of Pediatrics has recommended that well child visits for adolescents (ages 11-17 years) to include screening for depression.  The PHQ -2 which asks about loss of interest and pleasure in doing things and feeling down, depressed or hopeless has good sensitivity and specificity for detecting major depression. https://www.ncbi.nlm.nih.gov/books/NBK576416/   These properties, coupled with the brief nature of the instrument, make this tool promising as a first step for screening for adolescent depression in primary care.  A positive response to the PHQ-2 should trigger a specific question about the potential presence of suicidal ideation and/or intent—this include in the PHQ-9.  https://www.hrsa.gov/behavioral-health/phq-9-modified-teens

Adolescents will sometimes turn to drugs, like alcohol or marijuana or cigarettes/e-cigarettes, to self-medicate. If they are using on a regular basis, the use can be contributing to their depressive symptoms, and psychoeducation about that interaction will be important. Ongoing regular drug use can also limit the efficacy of a medication treatment for depression. Therefore, it is important to talk with teens about limiting their drug use if they are interested in a medication intervention.

In terms of general treatment guidelines, consider referral for therapy alone for mild-moderate cases of depression and consider combination of therapy with medication for moderate-severe cases of MDD, particularly if there is a significant impairment from their symptoms. Fluoxetine is the medication that has been studied the most for MDD in children and adolescents, but the other SSRIs, like citalopram, escitalopram and sertraline, can also be utilized. Fluoxetine has some advantage in having a longer half-life as teens may have difficulty with routine med compliance.  Other options to consider are bupropion and mirtazapine—bupropion may be consider if issues of co-morbid ADHD are of concern. The antidepressants to consider avoiding include: paroxetine and venlafaxine (because of their short half-lives, there is a higher risk of side effects and discontinuation symptoms with inconsistent use) and duloxetine (because of limited data in children and adolescents).

It is important to conduct a slower titration, starting with ½ the usual starting dose, to minimize the risk of side effects including akathisia (internal restlessness), behavioral activation and increased anxiety. So, for example, if considering fluoxetine, a starting dose of 10mg q day would be appropriate with a plan to increase to 20mg after 2-4 weeks if well tolerated and needed. It is important to discuss the length of time it can take for a patient to see a full positive result, so that the teen and family is realistic with their expectations. It is also important to alert the youth and family about the FDA black box warning about the increase in risk of spontaneous reports of suicidal thinking which should trigger a risk assessment and follow-up, particularly when medication is started or when the dose has been increased.   Care should be taken if dosing of an antidepressant has been increased to higher level dosing to monitor for possible excessive activation with agitation or hypo-mania.

SmartCare BHCS’ provider consultation line (858) 880-6405 may be a helpful resource when issues arise and the Family Support line (858) 956-5900 may be a resource for parents and older teens.

References:

Screening of Depression and Suicide in Children; Updated June 21, 2023    https://www.ncbi.nlm.nih.gov/books/NBK576416/

PHQ-( Modified for Teens:  https://www.hrsa.gov/behavioral-health/phq-9-modified-teens

Depression is highly co-morbid with other psychiatric disorders, like anxiety disorders, substance abuse disorders and disruptive behavior disorders. If an adolescent is presenting with depressive symptoms, it is important to take a careful history of bipolar symptoms (including current and past manic, hypomanic or psychotic symptoms), family history of bipolar disorders, and history of medication-induced manic or hypomanic symptoms. Twenty percent of children and adolescents with depression go on to develop some degree of bipolar symptomatology as adults with symptoms of fluctuating moods and mood lability. Retrospective surveys also indicate that the typical timeline for adults with bipolar disorder indicated that they first experienced depressive symptoms starting in childhood or adolescence.

In 2014, the American Academy of Pediatrics updated their well child visits for adolescents (ages 11-17 years) to include screening for depression.  The PHQ-2 (PHQ 2) has good sensitivity and specificity for detecting major depression. These properties, coupled with the brief nature of the instrument, make this tool promising as a first step for screening for adolescent depression in primary care.  The more detailed PHQ-9 Adolescent ( PHQ 9 Adolescent ) can be administered for positive findings on the PHQ-2.

Adolescents will sometimes turn to drugs, like alcohol or marijuana or cigarettes/e-cigarettes, to self-medicate. If they are using on a regular basis, the use can be contributing to their depressive symptoms, and psycho-education about that interaction will be important. Ongoing regular drug use can also limit the efficacy of a medication treatment for depression. Therefore it is important to talk with teens about limiting their drug use if they are interested in a medication intervention.

In terms of general treatment guidelines, consider therapy alone for mild-moderate cases of MDD and consider combination therapy and medication treatment for moderate-severe cases of MDD, particularly if there is a significant impairment from their symptoms. Fluoxetine is the medication that has been studied the most for MDD in children and adolescents, but the other SSRIs, like citalopram, escitalopram and sertraline, can also be utilized. Other options to consider are bupropion and mirtazapine. The antidepressants to consider avoiding include: paroxetine and venlafaxine (because of their short half-lives, there is a higher risk of side effects and discontinuation symptoms with inconsistent use) and duloxetine (because of limited data in children and adolescents).

It is important to conduct a slower titration, starting with ½ the usual starting dose, to minimize the risk of side effects including akathisia (internal restlessness), behavioral activation and increased anxiety. So, for example, if considering fluoxetine, a starting dose of 10mg q day would be appropriate with a plan to increase to 20mg after 2 weeks if tolerated and needed.  Advancing the dose higher may be warranted but should be done after 3-4 weeks on a standard therapeutic dose and with care and with close follow up as to efficacy and to assess for potential side effects.  It is important to discuss the length of time it can take for a patient to see a full positive result, so that the teen and family is realistic with their expectations. It is also important to carefully discuss with the teen and family the FDA black box warning about the increase in risk of spontaneous reporting of suicidal thinking and have close monitoring (follow-up in 1-2 weeks either in person or by phone), particularly when medication is started or when the dose is being increased.

Helpful resources for families:

• https://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Depression_Resource_Center/Depression_Resource_Center.aspx
• https://www.appi.org/dulcan

Front line treatments are well known, and include:

1. various forms and types of psychotherapies (individual and/or family, DBT, IPT, etc.),
2. medications such as the selective serotonin re-uptake inhibitors (SSRIs), selective norepinephrine uptake inhibitors (SNRIs), and others, and
3. various supportive interventions, such as school supports and increasing social activities.

Each of the above interventions have established benefits (and limitations) but the general consensus is that multi-modal interventions, where indicated and as feasible, are appropriate approaches in treatment of depressive (and most other) disorders.   When depression presents with mild to modest levels of symptoms, skillful evaluation and psychotherapeutic interventions are typically recommended as the first of these first line therapies to be suggested.

When presenting symptoms are more profound or when psychotherapy and supportive services are not having desired impact, consideration should be given to the initiation of psychopharmacologic intervention(s) in conjunction with ongoing outpatient services.  When presentations include concerns about potential harm, referral to a higher level of care need to be considered.

For a review of these basics, feel free to search our SmartCare newsletter library at www.vistahillccyp.org/ or reach out to the SmartCare provide line at 858 880-6405.

Supplemental treatment interventions of note:   Following is a brief discussion of some other complementary and/or alternative interventions that have evolving, but generally favorable (and, at worst, no major negative) evidence of potential efficacy that can be considered for implementation for patients and/or parents seeking to utilize them as supplemental interventions.

• Vitamin D deficiency is a known risk factor for depression but use of Vitamin D in depressed patients has generally proved challenging to affirm as of definitive benefit across all patients and blood levels can vary considerably across the population.  This said, multiple studies have looked at the role of vitamin for adolescents with depression (Libuda et al., 2020; Focker et al., 2018), and Libuda et al. found in a randomized control trial that youth with Vitamin D deficiency and depression treated with 2640 IU of Vit D3 per day had significant improvement in parental ratings of depressive symptoms.  More studies are needed, but this data suggests that offering supplemental treatment for youth with suspected vitamin D deficiency with depression may be worthwhile.
• Exercise, Yoga and Meditation (Cullen et al., 2019), not surprisingly, is generally believed to have a role in the augmenting treatment of depression, and preliminary data is positive. More research is certainly required, but these elements fit in well with the theoretical underpinnings of cognitive behavioral therapy, and current perspectives of health and wellness. It makes sense to encourage adolescents to take advantage of opportunities for the activities.
• Fish Oil, or Omega-3 fatty acids are also being studied. While there is not strong evidence for the role of Fish Oil as a specific treatment, there is ongoing investigation (Haberling et al., 2019).  We expect there to be more interest and information in this in the upcoming years.

Altering Diet, with attention to specific supplements may play a role in the future (Cullen et al., 2019). Currently data is preliminary

Cullen, K. R., Padilla, L. E., Papke, V. N., & Klimes-Dougan, B. (2019). New Somatic Treatments for Child and Adolescent Depression. Current treatment options in psychiatry, 6(4), 380–400. https://doi.org/10.1007/s40501-019-00194-8

Häberling, I., Berger, G., Schmeck, K., Held, U., & Walitza, S. (2019). Omega-3 Fatty Acids as a Treatment for Pediatric Depression. A Phase III, 36 Weeks, Multi-Center, Double-Blind, Placebo-Controlled Randomized Superiority Study. Frontiers in psychiatry, 10, 863. https://doi.org/10.3389/fpsyt.2019.00863

Libuda L, Timmesfeld N, Antel J, Hirtz R, Bauer J, Führer D, Zwanziger D, Öztürk D, Langenbach G, Hahn D, Ring S, Peters T, Hinney A, Bühlmeier J, Hebebrand J, Grasemann C, Föcker M. Effect of vitamin D deficiency on depressive symptoms in child and adolescent psychiatric patients: results of a randomized controlled trial. Eur J Nutr. 2020 Dec;59(8):3415-3424. doi: 10.1007/s00394-020-02176-6. Epub 2020 Feb 27. PMID: 32108263; PMCID: PMC7669774.

Föcker, M., Antel, J., Grasemann, C., Führer, D., Timmesfeld, N., Öztürk, D., Peters, T., Hinney, A., Hebebrand, J., & Libuda, L. (2018). Effect of an vitamin D deficiency on depressive symptoms in child and adolescent psychiatric patients – a randomized controlled trial: study protocol. BMC psychiatry, 18(1), 57. https://doi.org/10.1186/s12888-018-1637-7

Perinatal depression can affect women during pregnancy and up to one year after delivery. This includes the pregnancy (or antepartum) as well as the postpartum period. The CDC reports that 15-20% of women experience perinatal depression. Studies have shown that about 50% of women with perinatal depression go undiagnosed and untreated. It is one of the most common and costly obstetrical complications in the United States when under-recognized.

Some of the reasons for current low rates of perinatal screening include: ongoing stigma associated with mental health conditions, system level challenges when it comes to training providers and paying them to screen, and new parents’ hesitation to admit to emotional struggles when they are supposed to feel happy. New mothers worry about being judged as being inadequate.

There are several risk factors for the development of perinatal depression. These include: family and personal history of depression, substance abuse, marital discord, family violence, isolation, poverty, difficult infant temperament, young maternal age and chronic illness. Risk is also higher for teen mothers, mothers with multiple births and preterm births.

The risks associated with perinatal depression are many. During pregnancy, a woman might not seek adequate prenatal care and the baby is at risk to be born prematurely and with low birth weight. Once the baby is born, there can be feeding concerns and struggles with breastfeeding. Social emotional risks include trouble with maternal-infant bonding and poor attachment. Additionally, the mother can have a distorted perception of the infant’s behavior and impaired attention and judgment concerning safety. In the longer run, there could be negative effects on the infant’s brain development.

The AAP policy statement recommends that doctors screen women for perinatal depression once during pregnancy and again at the baby’s 1, 2, 4 and 6 month checkups. The Edinburgh Postnatal Depression Scale and Postpartum Depression Screening Scale are useful screening tools. This involves involvement by ob-gyns as well as primary care physicians (pediatricians, family medicine doctors). New fathers are also vulnerable to depression in the postpartum period and it is important to screen and refer them as well to treatment if needed. It is important for providers to be able to refer patients who screen positively for ongoing assessment and resources for support and treatment.

The AAP updated policy statement comes as a good reminder that helping a mother’s wellbeing and emotional health helps the baby’s health. Screening for perinatal depression during doctor’s visits for the baby helps bridge the gap for those mothers with depression to get treatment and support. Families can be referred to SmartCare BHCS for specific linkage to resources.

References:

https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/Infants-Family-Are-Affected-by-Mothers-Perinatal-Depression.aspx

Consistent with a biopsychosocial model of illness, individuals with chronic pain often report that the pain interferes with their ability to engage in occupational and recreational activities. Their inability to engage in these activities can contribute to increased isolation, feelings of worthlessness and hopelessness, sleep disturbance, and depressed mood. It is estimated that ¼ of patients with chronic pain meet criteria for major depression. In addition, conditions such as anxiety, substance abuse and personality disorders occur at a greater rate in individuals who have a chronic pain condition than individuals who do not.

Depression and pain strongly reinforce each other. Therefore it is important to treat both concurrently in order to have the greatest chance for success.  Both antidepressants and anticonvulsants can be used for treating chronic pain. The types of pain that are most responsive to these medications are neuropathic syndromes, such as diabetic neuropathy, trigeminal neuropathy, and post-herpetic neuralgia.  Chronic headaches, migraines, fibromyalgia, arthritis pain, and chronic low back pain may also be treated successfully with these medications.  Combined use may be appropriate for some patients.

In terms of antidepressant medications, tricyclic antidepressants and serotonin norepinephrine reuptake inhibitors (SNRIs) have been found to be particularly helpful. The SSRIs have not been found to be particularly helpful on their own for pain specifically but definitely are helpful for the co-morbid depression frequently seen in patients with chronic pain. Alternatively, a combination of SSRI and low dose tricyclic medication can be helpful more specifically for the pain symptoms of a chronic pain syndrome which include sleep disturbance as a significant symptom.

In terms of anticonvulsant medications, carbamazepine, depakote, lamotrigine and gabapentin have the most evidence for being helpful for chronic pain syndromes. Lamotrigine and gabapentin have fewer drug interactions and don’t require blood monitoring, making them easier to use in general.

One of the most effective psychological approaches for pain management is based on a cognitive-behavioral therapy (CBT) approach. Its aim is to change maladaptive thoughts and behaviors that serve to maintain and exacerbate the experience of pain, to introduce relaxation training, and to promote increased activity and functioning. Alternative pain treatments like physical therapy and acupuncture/acupressure can also be considered.

In summary, when treating a patient with chronic pain, it is important to assess how the pain is affecting their quality of life and try to concurrently treat their chronic pain, their emotional discomfort and their overall functional capacity whenever possible.

•  Fatigue/low energy
•  Trouble initiating or maintaining sleep
•  Hypersomnia
•  Significant change in appetite, leading to change to weight
• Poor concentration
• Depressed mood

When someone presents with new onset depressive symptoms, it is important to obtain a thorough history, conduct a review of systems to determine if there are abnormal findings in other body systems, obtain a family history, and perform a physical exam. These can point the provider in the right direction in terms of a differential diagnosis. Medical conditions that can mimic symptoms of depression include:

• Hypothyroidism
• B12 deficiency
• Iron deficiency anemia
• Autoimmune disorders – fibromyalgia, lupus
• Sleep apnea
• Seasonal allergies
• Medication side effect – ex: pain medication, beta blockers, Accutane, Chantix

If there is a concern for a medical condition leading to depressive symptoms, consider appropriate lab tests and imaging studies to confirm or rule out the diagnosis. To be clear, not everyone who presents with depressive symptoms needs to have other medical conditions ruled out, just in situations when it makes sense clinically.

Case Study:
9 year old female who presents with fatigue and low energy and trouble with concentration x 2 months. She reports she does not understand why she feels so tired because she sleeps 7-8 hours per night. The daytime fatigue is causing her to feel sad some days because it is affecting her energy level with her 1 year old and at work. She does not have a history of depression. Medically she is healthy except she experienced significant blood loss during her delivery.

Next Steps?
Given that she does not have a history of depression, it is important to rule out other medical causes for her symptoms. Basic labs are ordered and show low Hb/Hct. Additional studies ordered to assess for iron-deficiency anemia and confirm the diagnosis. She is started on iron supplementation and encouraged to eat more iron- rich foods in her diet and sees improvement in her symptoms over the next 3 months.
It is hopeful that this discussion and case example give clearer guidelines on when to consider a medical workup for a patient presenting with classically depressive symptoms. One take home point is that it is important to conduct a brief review of systems even in a patient presenting with depressive symptoms as her chief complaint.

Call: Provider Consultations 858-880-6405 Email: BHCS.provider@vistahill.org Webpage: www.pc2education.org

When assessing inattention, it is important to consider all possible causes, including: depression, anxiety, reaction to trauma, family or psychosocial stressor, a learning disability, a sensory processing issue, mental retardation, poor educational fit, brain injury, substance abuse, and rarely psychosis. If these other causes have been considered and ruled out, the inattention symptoms are impairing in both the home and school settings and the symptoms began before age 7, then a diagnosis of ADHD is likely. A treatment course involving a stimulant medication will likely be helpful. Likewise if a diagnosis of ADHD has been made but a child does not respond to multiple medication trials including stimulants and non-stimulants, then the treating clinician should reconsider the diagnosis.

Here are two case examples to illustrate the point:

1. 14yo female presents with a chief complaint of “trouble focusing”. She previously maintained good grades and did not have concerns of inattention, hyperactivity or impulsivity in early childhood. She now has failing grades. Associated symptoms include: irritability, poor sleep, isolation including from friends and non-suicidal self-injury for the last 2 months. She has a family history of depression in her mother and maternal GM and older sister.

-This presentation is more consistent with a diagnosis of Major Depression than ADHD. Patients with depression commonly report poor concentration and trouble with attention. A diagnosis of ADHD would not be consistent with this presentation because the patient did not have symptoms begin before age 7. A good treatment plan would be to consider an SSRI and individual therapy. While a stimulant may have helped with her inattention, it would not have helped with her other depressive symptoms.

2. 6yo boy presents with a chief complaint of  “inattention and impulsivity” primarily in the school setting. This child is in protective custody after being removed from bio parents because of physical abuse and neglect. He was not in school prior to the removal and was mostly isolated at home. He also presents with delays in speech and cognitive development as well as anxiety and aggression.

-This case example is more complicated because there are factors related to trauma, as well as developmental and educational delays. It would be important to fully evaluate those delays (including a speech evaluation and cognitive evaluation) and to ensure that he is in an appropriate educational placement prior to considering a diagnosis of ADHD. Also because of the co-morbid anxiety, a stimulant may not be the best medication choice as stimulants can make anxiety worse. Other options might be atomoxetine or guanfacine. Until a more thorough assessment can be completed, a more appropriate diagnosis might be Adjustment Disorder with Disturbance of Conduct and Emotion.

Hopefully this discussion and these case examples help illustrate the importance of a thorough assessment when a child presents with a chief complaint of “trouble focusing”, prior to beginning treatment. Since most patients will first present to their primary care provider with this concern, it is important for primary care providers to be comfortable beginning that assessment process .

In the past, OCD was categorized diagnostically as an anxiety disorder, but in the DSM V it has been separated into its own category. This is largely because research has shown that the genetics of OCD is different from the genetics of other anxiety disorder. OCD is defined as obsessions (intrusive, unwanted and excessive worries) and compulsions (rituals to relieve the anxiety) that are impairing to everyday life. The impairment can be defined by the amount of time spent on the obsessions and compulsions, its effect on preventing a patient from carrying out activities of daily living and work responsibilities, and its effect on alienating important people in the patient’s life. The obsessions and compulsions can involve the following: preoccupation with contamination, cleaning, checking, symmetry and order, preoccupation with sexual, violent or religious thoughts, and hoarding.

The diagnosis of OCD is primarily a clinical one. Two good screening questions to determine if further assessment is indicated are:

1. “Are bothered by unpleasant worries that repeatedly come into your mind about contamination, ordering things, etc?
2. “Are driven to perform certain acts over and over again like checking locks or washing your hands excessively?”

The YBOCs is a good diagnostic tool for delineating specific symptoms and determining the level of severity and the patient’s level of insight. The patient is typically aware that the obsessions and compulsions are irrational and excessive but are compelled to do them anyways. This egodystonic nature of the illness is partly what leads to the suffering from OCD and can lead to an increased risk of suicide.  In rare cases, when patients are not aware that their obsessions and compulsions are irrational and excessive, they are said to have “poor insight” and their OCD is typically more treatment-resistant. These cases can often be difficult to differentiate from true psychotic delusions.

OCD is frequently co-morbid with other anxiety disorders, depressive disorders, and eating disorders in adults and ADHD and tic disorders in children. Treatment options include exposure response prevention (a CBT specifically geared for OCD) and psychotropic medications. ERP involves repeated exposure to situations that trigger the obsessive thoughts and having the patient gradually learn to tolerate the anxiety and resist the urge to perform the compulsions. Medication options include the SSRIs (Prozac, Paxil, Lexapro, Celexa, Zoloft, Luvox) and Anafranil (an older tricyclic antidepressant, used primarily for treatment resistant cases). Medication treatment involves slow titration to avoid worsening the anxiety, and patients often need higher doses for longer periods of time for a full effect. It is important to make sure patients are aware that it can take up to 3 months to get to a full effective dose. Most patients do better with a combination of medication and ERP. There are adjunctive medication options available if full symptom relief is not achieved with an SSRI alone. These include the second-generation antipsychotic medications. Surgery and ECT vs deep brain stimulation can be used for refractory cases.

Given that OCD is more prevalent than previously thought, it is important that first line providers are comfortable with knowing when to assess for OCD and how to pursue with treatment recommendations.

Guidelines exist to urge primary care providers and cardiologists who see patients with coronary artery disease to screen for depression and refer for treatment as appropriate. It is therefore worthwhile to review appropriate treatment recommendations, both pharmacological and non-pharmacological for these cases.

For mild-moderate cases and/or based on patient preference, a referral for psychotherapy can be warranted as a first line intervention. This removes the concern about problematic side effects that might occur from a medication intervention. Of course, close follow-up would be needed to make sure improvement in the depression is occurring with therapy or if there is a need to consider a medication intervention.

Multiple well-designed studies have shown the effectiveness of selective serotonin reuptake inhibitors (SSRIs) for treating depression in patients with coronary artery disease. The SSRIs sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro) and fluoxetine (Prozac), have been studied in short-term trials and found to be effective. Many of these studies have assessed for cardiovascular safety measures related to the prescribed medication, and most show no difference between the medication arm and placebo arm. The caveat is that most of these studies have looked at safety of short-term use of SSRIs but not long-term use in patients with coronary artery disease. This still needs to be studied.

Other antidepressant classes have either not been studied in patients with coronary artery disease or the use is not recommended. The tricylic antidepressants are not commonly used in patients with coronary artery disease because of possible side effects, including orthostatic hypotension, effects on cardiac conduction, and anticholinergic effects.

When considering an SSRI, it is important to pay attention to possible drug interactions. Strong 2D6 inhibitors like fluoxetine and paroxetine can increase blood levels of beta-blockers, which are commonly used in patients with coronary artery disease. Increased blood levels of beta-blockers can lead to bradycardia. SSRIs may also interact with antiplatelet agents and anticoagulants to raise the risk of bleeding but this needs to be studied more to determine the exact risk and resulting clinical implications. There have been concerns raised with respect to citalopram about QT interval prolongation at higher doses, but upon further investigation, the concern may be overstated.

The bottom line is that for patients with coronary artery disease who are assessed to also have depression, the first-line recommendation, especially for mild-moderate cases, should be psychotherapy, with consideration of an SSRI for moderate-severe cases or if psychotherapy is not effective on its own. If considering an SSRI, sertraline and escitalopram have been found to be effective with minimal concerns about problematic side effects. As always, primary care providers are welcome to consult with SmartCare PC2 to help determine a best treatment course of action.

Call: SmartCare PC2@ 858-880-6405

Email us @ pc2@smartcare.org

Visit our webpage: www.pc2education.org

The 19th Annual San Diego School Health Conference (formerly known as the School Health Leadership Conference) will be held at AMN Healthcare, 12400 High Bluff Drive, San Diego, CA  92130 on Saturday, November 5, 2016.

The conference is intended for Nurses, Physicians, School Nurses, Nurse Practitioners, Physician Assistants, health professionals, and medical and nursing students.

This year’s program will focus on topics that include Immunizations, Sports Medicine, Autism, Transgender, Mental Health and Gastrointestinal issues facing today’s students.

Go to for more details.   http://www.aapca3.org/

PMDD symptoms includes moderate to severe depressed mood, irritability, mood lability, anxiety, anger, difficulty concentrating, and insomnia that occur exclusively in the two weeks before menses and cause significant impairment in daily functioning. PMDD is distinguished from other psychiatric disorders by timing; patients have symptoms only during the luteal phase of the menstrual cycle and report normal mood during the follicular phase. On average, symptoms last 6 days and peak 2 days before menses.

In patients who take oral contraceptive pills (OCPs), it is important to assess if symptoms are present and as severe even when they are not taking the OCPs, to eliminate the possibility that the symptoms are a side effect of the OCPs.  Patients with PMS and PMDD profiles should also be screened for co-morbid mood and anxiety disorders with symptoms present throughout the month. It is also important to screen PMDD patients for abuse histories, as there is a high correlation and referral for psychosocial intervention may be indicated.

To help distinguish between PMDD and PMS, patients can keep a daily mood diary for at least 2 months. The Daily Record of Severity of Problems (http://pmdd.factsforhealth.org/drsp/drsp_month.pdf) is a useful tool.

There are a variety of treatment options for PMDD. Antidepressants that exclusively affect serotonergic transmission (citalopram, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine, and clomipramine) are effective and can be used on an on-off schedule during the luteal phase because they have a rapid onset of action compared to antidepressant effects for depression. The use of combined oral contraception (estrogen and progestin) is common and more effective than either alone. Drospirenone/ethinyl estradiol is FDA-approved for PMDD. GnRH agonists have been found to be helpful but have problematic side effects, including medical menopause. Non-medication approaches that show some promise includes bright light therapy, calcium supplementation and chasteberry.

PMDD is a serious mental health concern that can lead to significant impairment for those affected. It is important to have the tools to assess for this disorder and offer appropriate treatment when indicated.