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 young patients with depression go on to develop bipolar disorder as adults. The typical timeline is that adults with bipolar disorder will report they first experienced depressive symptoms starting in childhood or adolescence.

Adolescents will sometimes turn to drugs, like alcohol and marijuana, 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, if that is being considered, and 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 symptoms and consider combination therapy and medication treatment for moderate-severe symptoms, 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 consider 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 qday would be appropriate with a plan to increase to 20mg after 1-2 weeks if 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 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.  With open disclosure and judicious monitoring this relatively infrequent side effect can comfortably managed, typically without having to terminate the medication trial.

It is our hope that this e-Weekly is helpful for primary care providers to develop comfort with assessing and treating adolescents with depression, as it is a fairly common presenting concern in the primary care office.

There has been a clear and steady increase in the number of adults reporting use of cannabis since 2000. Interestingly and fortunately, there is not an increase in the number of teens using cannabis, nor are there findings of teens starting to use at younger ages, but teens who are using are using more frequently than in the past and the potency of current supplies are greater than in the past, raising significant risk concerns.

Following are suggested harm reduction recommendations that seem appropriate to use with patients of any age to minimize potential negative consequences of cannabis use.

1. Using it less frequently and avoiding daily use
2. Delaying starting it until adulthood
3. Using safer sources and routes
4. Avoiding driving or being driven by someone under the influence

Although research findings are still somewhat limited, several studies have looked into the negative effects of cannabis use in adolescence which include: increased risk of psychosis, increased risk of substance dependence, and reduction of cognitive skills. Regular cannabis use can increase the risk of subclinical psychotic symptoms, and these symptoms can persist even after a long period of abstinence. Additionally, for patients with schizophrenia, using cannabis can move up the onset of schizophrenia up to 3 years earlier than for patients who do not use cannabis. Regular and heavy cannabis use in adolescence can lead to a permanent loss of IQ points, something that is not seen with cannabis use that starts in adulthood. Regular cannabis use in teens has been shown to impair learning, problem-solving skills and short-term and long-term memory. Studies also suggest downward socioeconomic mobility in people who started to use cannabis at a young age. The take home message is that if a teenager is using or at risk of using cannabis, they should be encouraged ideally to wait until adulthood or, absent abstinence, to avoid using it routinely because of these risks.

It is important for all patients, regardless of their age, to be aware of the sources of cannabis they are using and the route they are ingesting it by. It is particularly important for them to avoid products that are very high in THC (trans-Δ9-tetrahydrocannabino) and to avoid concentrates, which can be made in unsafe environments, and especially synthetic cannabinoids, which can be very potent and can have significant negative psychological impacts. Edibles and vaporized cannabis can be safer routes, because they do not irritate the respiratory system, but again, psychological impacts remain an obvious concern as dosing may be higher than anticipated, especially for new users.

It is recommended that providers discuss these issues in a fact oriented and non-judgmental manner just as one might inquire about alcohol or other substance use/abuse.  In the face of the changes in social attitudes and the change toward the legality of using cannabis for those over the age of 21, establishing and maintaining an active dialogue with all patients about substance use issues is recommended as part of routine care.

Patients acknowledging problems with dependence or misuse of cannabis should be referred for treatment to a mental health provider or a cannabis specific treatment program.

The San Diego Access and Crisis Line can offer options for your patients seeking treatment.  1-888-724-7240

References:

http://www.psychcongress.com/article/managing-cannabis-use-and-its-potential-risks