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

Although depression is common in the primary care setting, accurate identification of these patients is challenging.  This is a brief overview of the most common, accurate and most time efficient screening tools that address depression in adults, adolescents and perinatal women.  Links to each of the tools is provided at the end of the article.

ADULTS: Depression has been associated with poorer outcomes in patients with a variety of medical conditions, such as coronary artery disease, diabetes mellitus, and stroke. Treatment of depression may reduce mortality from these conditions, as well as help prevent suicide. Therefore, accurately identifying patients who have depression is important so that appropriate treatment can be initiated.

The most widely used and best-validated instruments in primary care are the PHQ-9 and its two-item version, the PHQ-2.   The PHQ-2 is similar in accuracy to the PHQ-9, but does not allow for the evaluation of severity or impact on daily activities.

ADOLESCENTS: The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. The current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger.  No specific criteria for frequency of screening has been established at this time.

Two tools that have been most often studied are the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory.  The PHQ-A is more time efficient.

Treatment options for MDD in children and adolescents include pharmacotherapy, psychotherapy, collaborative care, psychosocial support interventions, and complementary and alternative medicine approaches.

PERINATAL WOMEN: Perinatal depression is one of the most common complications of pregnancy, affecting one in seven women.  It includes minor and major depressive episodes occurring during pregnancy or the first 12 months after delivery.  It often goes unrecognized because changes in sleep, appetite, and libido may be attributed to normal pregnancy and postpartum changes. The American College of Obstetricians and Gynecologists (ACOG) has released recommendations on screening women for perinatal depression at least once, with the purpose of increasing awareness of depression and lessening the effects it has on pregnant and postpartum women and their families. Pediatricians can capitalize on their relationships with families to help identify women with maternal depression.

The Edinburgh Postnatal Depression Scale and PHQ-9 are the two most commonly recommended.  Women with current depression or anxiety, a history of perinatal mood disorders, or risk factors for perinatal mood disorders warrant particularly close monitoring, evaluation, and assessment.

Although screening is important first step for detecting depression, screening by itself is insufficient to improve clinical outcomes and must be coupled with appropriate follow-up and treatment when indicated.  All positive screening results should lead to additional assessment that considers severity of depression and comorbid psychological problems (eg, anxiety, panic attacks, or substance abuse), alternate diagnoses, and medical conditions.

Staff at SmartCare are available to consult and assist with referring patients to the appropriate behavioral health resources, when indicated.

PHQ-9: http://www.cqaimh.org/pdf/tool_phq9.pdf

PHQ-A (Teens):  https://www.aacap.org/App_Themes/AACAP/docs/member_resources/toolbox_for_clinical_practice_and_outcomes/symptoms/GLAD-PC_PHQ-9.pdf

Edinburgh Postnatal Depression Scale: http://www.aafp.org/afp/2010/1015/p926.html

http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening.