Amy Cheung, MD

Last month, we introduced you to 15-year-old Jane, a teenager whose once bubbly personality had in the last few months been reduced to a mood of quiet sadness. Her responses to your questions were muted, unenthusiastic. While Jane gets to school every day and can often shake off her down mood when she’s with friends, her responses to the Kutcher Adolescent Depression scale suggest that she’s struggling. You conclude that Jane is experiencing an episode of mild depressive disorder.

How would you manage Jane’s case? And what would you do if her symptoms worsened?

What’s the preference of patient and family?

Begin your initial management of a patient like Jane by considering the treatment preferences of the patient and her family, the severity and urgency of the case, the availability of mental health services, and your own comfort level with managing mental health disorders. A key conclusion of the GLAD-PC (GuideLines for Adolescent Depression in Primary Care) collaborative, described in Part 1 of this series, was that family physicians, alone or in collaboration with mental health professionals, are competent to manage adolescent depression.¹ You may or may not choose to manage a patient like Jane yourself, but even if you refer, your initial management provides an essential bridge until the patient and her family are seen by mental health professionals.

Your initial management should include the following:

• education
• a treatment plan
• safety planning.

Step 1: Educate patient and parents

Help your patient to better understand what it means to have depression. Describe the signs and symptoms that led to the diagnosis of depression and review the natural history of the illness, including the chronic nature of the disorder and its tendency to recur. Explain, too, the impact that depression can have on different areas of functioning, such as school performance and peer relationships, and then review the treatment options. You or someone on your staff can provide this patient education initially, but it is also critical to connect the family to specific community resources for additional education, advocacy, and peer support.¹

To do this effectively, you need to establish links with mental health resources in the community, including mental health service providers, as well as patients and families who have dealt with adolescent depression and are willing to serve as resources to other teens and their families. The GLAD-PC toolkit, available at www.gladpc.org, provides patient education handouts and links to reputable Web sites, advocacy organizations, and peer support groups. Additional online resources are listed in TABLE 1.

TABLE 1
Online resources

Step 2: Work out a treatment plan

Developing a treatment plan that the patient and her parents can accept is critical. A plan that includes psychotherapy with a mental health provider, for example, won’t be acceptable to some patients and parents. They may refuse to participate, or their underlying mistrust may affect the outcome of treatment.^2,3 Other families may reject any therapeutic approach that includes psychotropic drugs.

Expectations about the benefits of treatment influence outcomes significantly, so that, too, is a topic to explore as the treatment plan is worked out.^3,4 Finally, the plan should include agreed-upon goals of treatment. For Jane, planned goals might include getting back into gymnastics or trying out for the school play.

Step 3: Plan for safety

Suicidality, including ideation, behaviors, or attempts, is common among adolescents with depression.^5,6 In studies of completed suicide, more than 50% of the victims had a diagnosis of depression.⁵ To keep your patient safe, develop an emergency communication mechanism for handling increased suicidality or acute crises. If the patient’s risk is high, as shown by a clear plan or intent, immediate hospitalization may be necessary.

If you determine that inpatient treatment is not needed, you need to be sure that adequate adult supervision and support are available; that the teenager does not have access to potentially lethal medications, knives and other sharp objects, or firearms; and that both the patient and parents understand that drugs and alcohol weaken inhibitions. You need to set up a contingency plan with the family that includes checking in with you at reasonable intervals to assure the teen’s safety.⁵

Establishing a safety plan is especially important during the period of diagnosis and initial treatment, when suicide risk is highest.⁶ Confidentiality is the norm in adolescent medicine, but a patient like Jane must understand that you will breach confidentiality if that is necessary to keep her safe from harm.

Treatment options: When active support is best

Selecting the appropriate treatment modality for your patient hinges, of course, on the severity of the teen’s depression. (For more information on how to determine the severity of a depressive episode, see the first installment of this series, “Adolescent depression: Is your young patient suffering in silence?” J Fam Pract. 2009;58:187-192.)

When caring for a patient like Jane who is suffering from mild depression, consider providing active support and monitoring during 6 to 8 weekly or biweekly visits before recommending antidepressant medication or psychotherapy. This approach is also indicated when depressed patients or their parents refuse other treatments.⁷

Active support and monitoring may include education, frequent follow-up, a prescribed regimen of exercise and leisure activities, referral to a peer support group, and review of self-management goals. Other resources for active monitoring can be found in the GLAD-PC toolkit (available at www.gladpc.org). Evidence from randomized controlled trials (RCTs) shows that a sizable percentage of young people with depression respond to nondirective supportive therapy and regular symptom monitoring.⁷ Furthermore, emerging data from the research literature, expert opinion, and patient and family preferences indicate that active support and monitoring from family physicians is an important therapeutic strategy.^7,8

Is therapy needed—and if so, what kind?

Adolescents with moderate or severe depression or patients with mild depression whose symptoms do not improve with active support and monitoring alone will likely require treatment with one of the evidenced-based treatments, such as psychotherapy or antidepressants. Referral to a mental health provider for further assessment or treatment may also be required, depending on the training of the physician.^7,8 If so, you and the mental health provider will need to negotiate your roles and responsibilities for ongoing management, with the input and approval of the patient and family.

Both cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) have been adapted to address major depressive disorder (MDD) in adolescents and have been shown to be effective in community as well as specialized settings.^9-11

CBT is time-limited and delivered individually or by 1 or 2 clinicians working with a group. Clinicians follow a manual to guide each session.¹² (A manual for therapists and a workbook for adolescents and parents can be downloaded from the Kaiser Permanente Center for Health Research Web site at http://www.kpchr.org/public/acwd/acwd.html.)

The focus of CBT is to change patients’ perception of themselves, their world, and others. CBT treats depression by identifying behavioral and cognitive patterns associated with depressive cycles. Examples of such patterns include the propensity to withdraw from pleasurable activities, or irritability that alienates family and friends just when the teenager needs them most. CBT helps teens identify these self-defeating patterns, encourages them to take part in activities they enjoy, helps develop or reactivate social skills important for maintaining positive social interactions, and helps teens to develop problem-solving strategies for resolving stressful situations.

CBT also aims to correct maladaptive beliefs associated with the patient’s depression. If, for instance, a patient believes she is worthless if she’s not accepted by the “popular” group at school, she is likely to become depressed and stay depressed as long as she is having difficulty connecting with her peers. CBT would help her examine that belief and learn to feel worthwhile even if she is not accepted by the “in” group. In general, CBT sessions are scheduled on a weekly basis for 12 to 16 weeks. In each session, the therapist and patient complete specific tasks and exercises that are provided in a CBT manual. There are also tasks for the patient to complete between sessions and review later with the therapist. CBT has been used in primary care with preliminary positive results.^13,14 However, the results of a recent RCT conducted in psychiatric settings demonstrated superior efficacy of combination therapy (fluoxetine and CBT) vs CBT alone.¹⁵

IPT for adolescents (IPT-A) is like CBT in that it is time-limited and clinicians are guided by a manual.¹⁶ A course of therapy can last anywhere from 12 to 16 sessions with optional maintenance treatment. The theoretical basis for IPT-A is the observed negative impact of depressive symptoms on interpersonal relationships, and the effect poor relationships have in causing and perpetuating depression. In deciding whether a patient may be suitable for IPT-A, you need to find out whether she would be willing to share her experiences of ongoing relationship conflicts with a therapist or therapeutic group. The relationship difficulties IPT-A is designed to help with arise from 1 of 4 sources: grief, fights with peers or family members (interpersonal disputes), transitions from one social surround to another (role transition), and friendlessness (interpersonal deficits).

IPT-A focuses on grief only when someone of significance to the patient has died. Therapy for teens who quarrel frequently with peers or family members is focused on interpersonal disputes, and this is the most common focus in IPT-A. A focus on role transition is called for when the teen’s social world has undergone a drastic change, such as a when a teen has moved to a new school or broken up with a boyfriend. Finally, therapy for a teen with no significant relationships outside the immediate family focuses on interpersonal deficits. In these cases, the goal of therapy is to increase social contact and help the patient build relationships. If your preliminary assessment identifies your patient’s difficulties as rooted in 1 of these 4 areas, IPT-A may be for her.

Because few family physicians are trained in CBT or IPT-A, most psychotherapy will be provided by mental health professionals. What you can provide is familiarity with available community mental health resources. To get to know the therapists in your community, you may want to reach out to a few of them and ask them the questions in TABLE 2. You may also want to share this list with parents who want to find their own therapist.

TABLE 2
6 questions to ask prospective therapists

Choose an antidepressant, monitor with care

Studies have shown that up to 42% of family physicians in the United States had recently prescribed selective serotonin reuptake inhibitors (SSRIs) for more than 1 adolescent under the age of 18.¹⁷ When the diagnosis of MDD without comorbid conditions is clear and the patient and family are amenable, you may want to prescribe an SSRI.^7,8

If you do, warn the patient and family that antidepressants can sometimes have adverse effects, including a switch from depressive to manic symptoms, signs of behavioral activation including agitation, hostility or restlessness, and suicidal ideation or behavior. If the patient can tolerate the medication without significant adverse effects, you need to prescribe the effective dose for at least 6 to 8 weeks to ensure an adequate trial.⁷

TABLE 3 provides some guidance for prescribing antidepressants for adolescents with depression.⁷ Among the antidepressants, only fluoxetine has been approved by the FDA for children and adolescents with depression. Fluoxetine is also the SSRI with the strongest evidence for efficacy in the adolescent population, as demonstrated in 4 RCTs.¹⁸ Two studies involving fluoxetine for depression have also shown efficacy in children as young as age 7 (range, 7-12 years).¹⁹

Effective dosages for antidepressants are lower for adolescents than for adults. Initiate medications at a low dose and increase in recommended increments every 2 weeks if no significant adverse effects emerge. With the exception of fluoxetine, SSRI medications must be discontinued slowly to minimize the risk of discontinuation effects.

Once treatment begins, you or a member of your staff will need to stay in touch with the patient and family to review their continued adherence to the treatment plan. An FDA black-box warning recommends observing for “clinical worsening, suicidality, and unusual changes in behavior” during initial visits or “at times of dose changes, either increases or decreases.” Develop a regular, frequent monitoring schedule with input from the teen and her (or his) parents to ensure compliance.^7,20

Make sure follow-up appointments are not missed, using flags in patient records or in the clinic schedule. The duration of treatment for teens with depression is yet to be determined through clinical trials. Most guidelines suggest drug therapy be continued at the same dosage for 6 to 12 months after symptoms resolve. Guidelines for the treatment of adolescent depression can be found at www.gladpc.org.

Keeping teenagers on an antidepressant regimen can be challenging, given the side effects, the amount of time it takes before they experience an improvement, and the lengthy duration of treatment. Families that know what to expect and are getting continuing support from you and others are most likely to stay with treatment for the duration.

TABLE 3
A guide to prescribing antidepressants for adolescents

What about Jane?

As the family’s physician, your initial management began with you educating Jane and her parents about mild depressive disorder and its likely course. You set up a series of weekly visits to monitor her symptoms and provide active support. You helped Jane find a peer support group and encouraged her to get back into gymnastics. You taught Jane and her family about the importance of keeping her safe while she is depressed, and they were cooperative about safety-proofing their home and setting up a plan to handle emergencies.

Jane’s depressive symptoms gradually ebbed, and she returned to her previous level of energy and social activity. You warned her and her family about the possibility that the disorder might recur, so they would be prepared.

Correspondence
Amy Cheung, MD, 33 Russell Street, 3rd Floor Tower, Toronto, Ontario, Canada MSS 2S1; dramy.cheung@gmail.com

Last month, we introduced you to 15-year-old Jane, a teenager whose once bubbly personality had in the last few months been reduced to a mood of quiet sadness. Her responses to your questions were muted, unenthusiastic. While Jane gets to school every day and can often shake off her down mood when she’s with friends, her responses to the Kutcher Adolescent Depression scale suggest that she’s struggling. You conclude that Jane is experiencing an episode of mild depressive disorder.

How would you manage Jane’s case? And what would you do if her symptoms worsened?

What’s the preference of patient and family?

Begin your initial management of a patient like Jane by considering the treatment preferences of the patient and her family, the severity and urgency of the case, the availability of mental health services, and your own comfort level with managing mental health disorders. A key conclusion of the GLAD-PC (GuideLines for Adolescent Depression in Primary Care) collaborative, described in Part 1 of this series, was that family physicians, alone or in collaboration with mental health professionals, are competent to manage adolescent depression.¹ You may or may not choose to manage a patient like Jane yourself, but even if you refer, your initial management provides an essential bridge until the patient and her family are seen by mental health professionals.

Your initial management should include the following:

• education
• a treatment plan
• safety planning.

Step 1: Educate patient and parents

Help your patient to better understand what it means to have depression. Describe the signs and symptoms that led to the diagnosis of depression and review the natural history of the illness, including the chronic nature of the disorder and its tendency to recur. Explain, too, the impact that depression can have on different areas of functioning, such as school performance and peer relationships, and then review the treatment options. You or someone on your staff can provide this patient education initially, but it is also critical to connect the family to specific community resources for additional education, advocacy, and peer support.¹

To do this effectively, you need to establish links with mental health resources in the community, including mental health service providers, as well as patients and families who have dealt with adolescent depression and are willing to serve as resources to other teens and their families. The GLAD-PC toolkit, available at www.gladpc.org, provides patient education handouts and links to reputable Web sites, advocacy organizations, and peer support groups. Additional online resources are listed in TABLE 1.

TABLE 1
Online resources

Step 2: Work out a treatment plan

Developing a treatment plan that the patient and her parents can accept is critical. A plan that includes psychotherapy with a mental health provider, for example, won’t be acceptable to some patients and parents. They may refuse to participate, or their underlying mistrust may affect the outcome of treatment.^2,3 Other families may reject any therapeutic approach that includes psychotropic drugs.

Expectations about the benefits of treatment influence outcomes significantly, so that, too, is a topic to explore as the treatment plan is worked out.^3,4 Finally, the plan should include agreed-upon goals of treatment. For Jane, planned goals might include getting back into gymnastics or trying out for the school play.

Step 3: Plan for safety

Suicidality, including ideation, behaviors, or attempts, is common among adolescents with depression.^5,6 In studies of completed suicide, more than 50% of the victims had a diagnosis of depression.⁵ To keep your patient safe, develop an emergency communication mechanism for handling increased suicidality or acute crises. If the patient’s risk is high, as shown by a clear plan or intent, immediate hospitalization may be necessary.

If you determine that inpatient treatment is not needed, you need to be sure that adequate adult supervision and support are available; that the teenager does not have access to potentially lethal medications, knives and other sharp objects, or firearms; and that both the patient and parents understand that drugs and alcohol weaken inhibitions. You need to set up a contingency plan with the family that includes checking in with you at reasonable intervals to assure the teen’s safety.⁵

Establishing a safety plan is especially important during the period of diagnosis and initial treatment, when suicide risk is highest.⁶ Confidentiality is the norm in adolescent medicine, but a patient like Jane must understand that you will breach confidentiality if that is necessary to keep her safe from harm.

Treatment options: When active support is best

Selecting the appropriate treatment modality for your patient hinges, of course, on the severity of the teen’s depression. (For more information on how to determine the severity of a depressive episode, see the first installment of this series, “Adolescent depression: Is your young patient suffering in silence?” J Fam Pract. 2009;58:187-192.)

When caring for a patient like Jane who is suffering from mild depression, consider providing active support and monitoring during 6 to 8 weekly or biweekly visits before recommending antidepressant medication or psychotherapy. This approach is also indicated when depressed patients or their parents refuse other treatments.⁷

Active support and monitoring may include education, frequent follow-up, a prescribed regimen of exercise and leisure activities, referral to a peer support group, and review of self-management goals. Other resources for active monitoring can be found in the GLAD-PC toolkit (available at www.gladpc.org). Evidence from randomized controlled trials (RCTs) shows that a sizable percentage of young people with depression respond to nondirective supportive therapy and regular symptom monitoring.⁷ Furthermore, emerging data from the research literature, expert opinion, and patient and family preferences indicate that active support and monitoring from family physicians is an important therapeutic strategy.^7,8

Is therapy needed—and if so, what kind?

Adolescents with moderate or severe depression or patients with mild depression whose symptoms do not improve with active support and monitoring alone will likely require treatment with one of the evidenced-based treatments, such as psychotherapy or antidepressants. Referral to a mental health provider for further assessment or treatment may also be required, depending on the training of the physician.^7,8 If so, you and the mental health provider will need to negotiate your roles and responsibilities for ongoing management, with the input and approval of the patient and family.

Both cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) have been adapted to address major depressive disorder (MDD) in adolescents and have been shown to be effective in community as well as specialized settings.^9-11

CBT is time-limited and delivered individually or by 1 or 2 clinicians working with a group. Clinicians follow a manual to guide each session.¹² (A manual for therapists and a workbook for adolescents and parents can be downloaded from the Kaiser Permanente Center for Health Research Web site at http://www.kpchr.org/public/acwd/acwd.html.)

The focus of CBT is to change patients’ perception of themselves, their world, and others. CBT treats depression by identifying behavioral and cognitive patterns associated with depressive cycles. Examples of such patterns include the propensity to withdraw from pleasurable activities, or irritability that alienates family and friends just when the teenager needs them most. CBT helps teens identify these self-defeating patterns, encourages them to take part in activities they enjoy, helps develop or reactivate social skills important for maintaining positive social interactions, and helps teens to develop problem-solving strategies for resolving stressful situations.

CBT also aims to correct maladaptive beliefs associated with the patient’s depression. If, for instance, a patient believes she is worthless if she’s not accepted by the “popular” group at school, she is likely to become depressed and stay depressed as long as she is having difficulty connecting with her peers. CBT would help her examine that belief and learn to feel worthwhile even if she is not accepted by the “in” group. In general, CBT sessions are scheduled on a weekly basis for 12 to 16 weeks. In each session, the therapist and patient complete specific tasks and exercises that are provided in a CBT manual. There are also tasks for the patient to complete between sessions and review later with the therapist. CBT has been used in primary care with preliminary positive results.^13,14 However, the results of a recent RCT conducted in psychiatric settings demonstrated superior efficacy of combination therapy (fluoxetine and CBT) vs CBT alone.¹⁵

IPT for adolescents (IPT-A) is like CBT in that it is time-limited and clinicians are guided by a manual.¹⁶ A course of therapy can last anywhere from 12 to 16 sessions with optional maintenance treatment. The theoretical basis for IPT-A is the observed negative impact of depressive symptoms on interpersonal relationships, and the effect poor relationships have in causing and perpetuating depression. In deciding whether a patient may be suitable for IPT-A, you need to find out whether she would be willing to share her experiences of ongoing relationship conflicts with a therapist or therapeutic group. The relationship difficulties IPT-A is designed to help with arise from 1 of 4 sources: grief, fights with peers or family members (interpersonal disputes), transitions from one social surround to another (role transition), and friendlessness (interpersonal deficits).

IPT-A focuses on grief only when someone of significance to the patient has died. Therapy for teens who quarrel frequently with peers or family members is focused on interpersonal disputes, and this is the most common focus in IPT-A. A focus on role transition is called for when the teen’s social world has undergone a drastic change, such as a when a teen has moved to a new school or broken up with a boyfriend. Finally, therapy for a teen with no significant relationships outside the immediate family focuses on interpersonal deficits. In these cases, the goal of therapy is to increase social contact and help the patient build relationships. If your preliminary assessment identifies your patient’s difficulties as rooted in 1 of these 4 areas, IPT-A may be for her.

Because few family physicians are trained in CBT or IPT-A, most psychotherapy will be provided by mental health professionals. What you can provide is familiarity with available community mental health resources. To get to know the therapists in your community, you may want to reach out to a few of them and ask them the questions in TABLE 2. You may also want to share this list with parents who want to find their own therapist.

TABLE 2
6 questions to ask prospective therapists

Choose an antidepressant, monitor with care

Studies have shown that up to 42% of family physicians in the United States had recently prescribed selective serotonin reuptake inhibitors (SSRIs) for more than 1 adolescent under the age of 18.¹⁷ When the diagnosis of MDD without comorbid conditions is clear and the patient and family are amenable, you may want to prescribe an SSRI.^7,8

If you do, warn the patient and family that antidepressants can sometimes have adverse effects, including a switch from depressive to manic symptoms, signs of behavioral activation including agitation, hostility or restlessness, and suicidal ideation or behavior. If the patient can tolerate the medication without significant adverse effects, you need to prescribe the effective dose for at least 6 to 8 weeks to ensure an adequate trial.⁷

TABLE 3 provides some guidance for prescribing antidepressants for adolescents with depression.⁷ Among the antidepressants, only fluoxetine has been approved by the FDA for children and adolescents with depression. Fluoxetine is also the SSRI with the strongest evidence for efficacy in the adolescent population, as demonstrated in 4 RCTs.¹⁸ Two studies involving fluoxetine for depression have also shown efficacy in children as young as age 7 (range, 7-12 years).¹⁹

Effective dosages for antidepressants are lower for adolescents than for adults. Initiate medications at a low dose and increase in recommended increments every 2 weeks if no significant adverse effects emerge. With the exception of fluoxetine, SSRI medications must be discontinued slowly to minimize the risk of discontinuation effects.

Once treatment begins, you or a member of your staff will need to stay in touch with the patient and family to review their continued adherence to the treatment plan. An FDA black-box warning recommends observing for “clinical worsening, suicidality, and unusual changes in behavior” during initial visits or “at times of dose changes, either increases or decreases.” Develop a regular, frequent monitoring schedule with input from the teen and her (or his) parents to ensure compliance.^7,20

Make sure follow-up appointments are not missed, using flags in patient records or in the clinic schedule. The duration of treatment for teens with depression is yet to be determined through clinical trials. Most guidelines suggest drug therapy be continued at the same dosage for 6 to 12 months after symptoms resolve. Guidelines for the treatment of adolescent depression can be found at www.gladpc.org.

Keeping teenagers on an antidepressant regimen can be challenging, given the side effects, the amount of time it takes before they experience an improvement, and the lengthy duration of treatment. Families that know what to expect and are getting continuing support from you and others are most likely to stay with treatment for the duration.

TABLE 3
A guide to prescribing antidepressants for adolescents

What about Jane?

As the family’s physician, your initial management began with you educating Jane and her parents about mild depressive disorder and its likely course. You set up a series of weekly visits to monitor her symptoms and provide active support. You helped Jane find a peer support group and encouraged her to get back into gymnastics. You taught Jane and her family about the importance of keeping her safe while she is depressed, and they were cooperative about safety-proofing their home and setting up a plan to handle emergencies.

Jane’s depressive symptoms gradually ebbed, and she returned to her previous level of energy and social activity. You warned her and her family about the possibility that the disorder might recur, so they would be prepared.

Correspondence
Amy Cheung, MD, 33 Russell Street, 3rd Floor Tower, Toronto, Ontario, Canada MSS 2S1; dramy.cheung@gmail.com

Last month, we introduced you to 15-year-old Jane, a teenager whose once bubbly personality had in the last few months been reduced to a mood of quiet sadness. Her responses to your questions were muted, unenthusiastic. While Jane gets to school every day and can often shake off her down mood when she’s with friends, her responses to the Kutcher Adolescent Depression scale suggest that she’s struggling. You conclude that Jane is experiencing an episode of mild depressive disorder.

How would you manage Jane’s case? And what would you do if her symptoms worsened?

What’s the preference of patient and family?

Begin your initial management of a patient like Jane by considering the treatment preferences of the patient and her family, the severity and urgency of the case, the availability of mental health services, and your own comfort level with managing mental health disorders. A key conclusion of the GLAD-PC (GuideLines for Adolescent Depression in Primary Care) collaborative, described in Part 1 of this series, was that family physicians, alone or in collaboration with mental health professionals, are competent to manage adolescent depression.¹ You may or may not choose to manage a patient like Jane yourself, but even if you refer, your initial management provides an essential bridge until the patient and her family are seen by mental health professionals.

Your initial management should include the following:

• education
• a treatment plan
• safety planning.

Step 1: Educate patient and parents

Help your patient to better understand what it means to have depression. Describe the signs and symptoms that led to the diagnosis of depression and review the natural history of the illness, including the chronic nature of the disorder and its tendency to recur. Explain, too, the impact that depression can have on different areas of functioning, such as school performance and peer relationships, and then review the treatment options. You or someone on your staff can provide this patient education initially, but it is also critical to connect the family to specific community resources for additional education, advocacy, and peer support.¹

To do this effectively, you need to establish links with mental health resources in the community, including mental health service providers, as well as patients and families who have dealt with adolescent depression and are willing to serve as resources to other teens and their families. The GLAD-PC toolkit, available at www.gladpc.org, provides patient education handouts and links to reputable Web sites, advocacy organizations, and peer support groups. Additional online resources are listed in TABLE 1.

TABLE 1
Online resources

Step 2: Work out a treatment plan

Developing a treatment plan that the patient and her parents can accept is critical. A plan that includes psychotherapy with a mental health provider, for example, won’t be acceptable to some patients and parents. They may refuse to participate, or their underlying mistrust may affect the outcome of treatment.^2,3 Other families may reject any therapeutic approach that includes psychotropic drugs.

Expectations about the benefits of treatment influence outcomes significantly, so that, too, is a topic to explore as the treatment plan is worked out.^3,4 Finally, the plan should include agreed-upon goals of treatment. For Jane, planned goals might include getting back into gymnastics or trying out for the school play.

Step 3: Plan for safety

Suicidality, including ideation, behaviors, or attempts, is common among adolescents with depression.^5,6 In studies of completed suicide, more than 50% of the victims had a diagnosis of depression.⁵ To keep your patient safe, develop an emergency communication mechanism for handling increased suicidality or acute crises. If the patient’s risk is high, as shown by a clear plan or intent, immediate hospitalization may be necessary.

If you determine that inpatient treatment is not needed, you need to be sure that adequate adult supervision and support are available; that the teenager does not have access to potentially lethal medications, knives and other sharp objects, or firearms; and that both the patient and parents understand that drugs and alcohol weaken inhibitions. You need to set up a contingency plan with the family that includes checking in with you at reasonable intervals to assure the teen’s safety.⁵

Establishing a safety plan is especially important during the period of diagnosis and initial treatment, when suicide risk is highest.⁶ Confidentiality is the norm in adolescent medicine, but a patient like Jane must understand that you will breach confidentiality if that is necessary to keep her safe from harm.

Treatment options: When active support is best

Selecting the appropriate treatment modality for your patient hinges, of course, on the severity of the teen’s depression. (For more information on how to determine the severity of a depressive episode, see the first installment of this series, “Adolescent depression: Is your young patient suffering in silence?” J Fam Pract. 2009;58:187-192.)

When caring for a patient like Jane who is suffering from mild depression, consider providing active support and monitoring during 6 to 8 weekly or biweekly visits before recommending antidepressant medication or psychotherapy. This approach is also indicated when depressed patients or their parents refuse other treatments.⁷

Active support and monitoring may include education, frequent follow-up, a prescribed regimen of exercise and leisure activities, referral to a peer support group, and review of self-management goals. Other resources for active monitoring can be found in the GLAD-PC toolkit (available at www.gladpc.org). Evidence from randomized controlled trials (RCTs) shows that a sizable percentage of young people with depression respond to nondirective supportive therapy and regular symptom monitoring.⁷ Furthermore, emerging data from the research literature, expert opinion, and patient and family preferences indicate that active support and monitoring from family physicians is an important therapeutic strategy.^7,8

Is therapy needed—and if so, what kind?

Adolescents with moderate or severe depression or patients with mild depression whose symptoms do not improve with active support and monitoring alone will likely require treatment with one of the evidenced-based treatments, such as psychotherapy or antidepressants. Referral to a mental health provider for further assessment or treatment may also be required, depending on the training of the physician.^7,8 If so, you and the mental health provider will need to negotiate your roles and responsibilities for ongoing management, with the input and approval of the patient and family.

Both cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) have been adapted to address major depressive disorder (MDD) in adolescents and have been shown to be effective in community as well as specialized settings.^9-11

CBT is time-limited and delivered individually or by 1 or 2 clinicians working with a group. Clinicians follow a manual to guide each session.¹² (A manual for therapists and a workbook for adolescents and parents can be downloaded from the Kaiser Permanente Center for Health Research Web site at http://www.kpchr.org/public/acwd/acwd.html.)

The focus of CBT is to change patients’ perception of themselves, their world, and others. CBT treats depression by identifying behavioral and cognitive patterns associated with depressive cycles. Examples of such patterns include the propensity to withdraw from pleasurable activities, or irritability that alienates family and friends just when the teenager needs them most. CBT helps teens identify these self-defeating patterns, encourages them to take part in activities they enjoy, helps develop or reactivate social skills important for maintaining positive social interactions, and helps teens to develop problem-solving strategies for resolving stressful situations.

CBT also aims to correct maladaptive beliefs associated with the patient’s depression. If, for instance, a patient believes she is worthless if she’s not accepted by the “popular” group at school, she is likely to become depressed and stay depressed as long as she is having difficulty connecting with her peers. CBT would help her examine that belief and learn to feel worthwhile even if she is not accepted by the “in” group. In general, CBT sessions are scheduled on a weekly basis for 12 to 16 weeks. In each session, the therapist and patient complete specific tasks and exercises that are provided in a CBT manual. There are also tasks for the patient to complete between sessions and review later with the therapist. CBT has been used in primary care with preliminary positive results.^13,14 However, the results of a recent RCT conducted in psychiatric settings demonstrated superior efficacy of combination therapy (fluoxetine and CBT) vs CBT alone.¹⁵

IPT for adolescents (IPT-A) is like CBT in that it is time-limited and clinicians are guided by a manual.¹⁶ A course of therapy can last anywhere from 12 to 16 sessions with optional maintenance treatment. The theoretical basis for IPT-A is the observed negative impact of depressive symptoms on interpersonal relationships, and the effect poor relationships have in causing and perpetuating depression. In deciding whether a patient may be suitable for IPT-A, you need to find out whether she would be willing to share her experiences of ongoing relationship conflicts with a therapist or therapeutic group. The relationship difficulties IPT-A is designed to help with arise from 1 of 4 sources: grief, fights with peers or family members (interpersonal disputes), transitions from one social surround to another (role transition), and friendlessness (interpersonal deficits).

IPT-A focuses on grief only when someone of significance to the patient has died. Therapy for teens who quarrel frequently with peers or family members is focused on interpersonal disputes, and this is the most common focus in IPT-A. A focus on role transition is called for when the teen’s social world has undergone a drastic change, such as a when a teen has moved to a new school or broken up with a boyfriend. Finally, therapy for a teen with no significant relationships outside the immediate family focuses on interpersonal deficits. In these cases, the goal of therapy is to increase social contact and help the patient build relationships. If your preliminary assessment identifies your patient’s difficulties as rooted in 1 of these 4 areas, IPT-A may be for her.

Because few family physicians are trained in CBT or IPT-A, most psychotherapy will be provided by mental health professionals. What you can provide is familiarity with available community mental health resources. To get to know the therapists in your community, you may want to reach out to a few of them and ask them the questions in TABLE 2. You may also want to share this list with parents who want to find their own therapist.

TABLE 2
6 questions to ask prospective therapists

Choose an antidepressant, monitor with care

Studies have shown that up to 42% of family physicians in the United States had recently prescribed selective serotonin reuptake inhibitors (SSRIs) for more than 1 adolescent under the age of 18.¹⁷ When the diagnosis of MDD without comorbid conditions is clear and the patient and family are amenable, you may want to prescribe an SSRI.^7,8

If you do, warn the patient and family that antidepressants can sometimes have adverse effects, including a switch from depressive to manic symptoms, signs of behavioral activation including agitation, hostility or restlessness, and suicidal ideation or behavior. If the patient can tolerate the medication without significant adverse effects, you need to prescribe the effective dose for at least 6 to 8 weeks to ensure an adequate trial.⁷

TABLE 3 provides some guidance for prescribing antidepressants for adolescents with depression.⁷ Among the antidepressants, only fluoxetine has been approved by the FDA for children and adolescents with depression. Fluoxetine is also the SSRI with the strongest evidence for efficacy in the adolescent population, as demonstrated in 4 RCTs.¹⁸ Two studies involving fluoxetine for depression have also shown efficacy in children as young as age 7 (range, 7-12 years).¹⁹

Effective dosages for antidepressants are lower for adolescents than for adults. Initiate medications at a low dose and increase in recommended increments every 2 weeks if no significant adverse effects emerge. With the exception of fluoxetine, SSRI medications must be discontinued slowly to minimize the risk of discontinuation effects.

Once treatment begins, you or a member of your staff will need to stay in touch with the patient and family to review their continued adherence to the treatment plan. An FDA black-box warning recommends observing for “clinical worsening, suicidality, and unusual changes in behavior” during initial visits or “at times of dose changes, either increases or decreases.” Develop a regular, frequent monitoring schedule with input from the teen and her (or his) parents to ensure compliance.^7,20

Make sure follow-up appointments are not missed, using flags in patient records or in the clinic schedule. The duration of treatment for teens with depression is yet to be determined through clinical trials. Most guidelines suggest drug therapy be continued at the same dosage for 6 to 12 months after symptoms resolve. Guidelines for the treatment of adolescent depression can be found at www.gladpc.org.

Keeping teenagers on an antidepressant regimen can be challenging, given the side effects, the amount of time it takes before they experience an improvement, and the lengthy duration of treatment. Families that know what to expect and are getting continuing support from you and others are most likely to stay with treatment for the duration.

TABLE 3
A guide to prescribing antidepressants for adolescents

What about Jane?

As the family’s physician, your initial management began with you educating Jane and her parents about mild depressive disorder and its likely course. You set up a series of weekly visits to monitor her symptoms and provide active support. You helped Jane find a peer support group and encouraged her to get back into gymnastics. You taught Jane and her family about the importance of keeping her safe while she is depressed, and they were cooperative about safety-proofing their home and setting up a plan to handle emergencies.

Jane’s depressive symptoms gradually ebbed, and she returned to her previous level of energy and social activity. You warned her and her family about the possibility that the disorder might recur, so they would be prepared.

Correspondence
Amy Cheung, MD, 33 Russell Street, 3rd Floor Tower, Toronto, Ontario, Canada MSS 2S1; dramy.cheung@gmail.com

You’ve known Jane since infancy. Now she’s 15 and in your office for her yearly checkup. As she comes into the exam room, you notice she’s gained a lot of weight since you saw her a year ago. She’s also missing the energy and sparkle that have always been such an engaging part of her personality. When you trot out your usual questions for teens—How’s school? Keeping up your grades? Going out for a team?—her answers are disquieting. School’s dull, her grades have gone downhill, and she’s dropped out of gymnastics. Her mother says Jane is irritable and sleeping a lot, and that worries her.

Could Jane be going through a bout of clinical depression?

Teen depression: Common, and commonly untreated

In North America, about 9% of all teenagers meet the criteria for depression at any given time, and prevalence rates in primary care are very likely higher.¹ One study in the 1990s found approximately 28% of teens presenting to a primary care office met criteria for depression.²

Although adolescents with depression frequently seek care in the primary care setting, most are not identified or treated because of any number of barriers.^3,4 First, mental illness continues to be highly stigmatized. As a result, many troubled teens (and parents of these teens) do not seek help.⁴ Second, mental health professionals trained to treat adolescents are in short supply, and most family physicians and other primary care clinicians feel inadequately trained, supported, or reimbursed for the management of this disorder.⁵ Third, the controversy over the safety and efficacy of antidepressants in the pediatric population has created an additional barrier to care.

In addition, while clinical guidelines for diagnosing and treating adolescent depression have been developed for specialty care settings,⁶ they are not easily transferred to primary care because of the significant differences between the primary and specialty care settings. Recognizing this gap in clinical guidance, a group of researchers and clinicians (including the authors of this report) from the United States and Canada established a collaborative to formulate primary care guidelines for adolescent depression (GuideLines for Adolescent Depression in Primary Care, or GLAD-PC). Details about the collaborative’s methods and recommendations were published in Pediatrics in 2007.^7,8 The accompanying clinician toolkit is available at www.gladpc.org.

This review summarizes the collaborative’s key findings and recommendations and includes evidence from additional research published since the completion of GLAD-PC in 2007. For simplicity’s sake, we use the term “depression” to refer to what is more formally known as major depressive disorder (MDD).

Red flags that you are well positioned to spot

As a family physician, you have the advantage of knowing the families in your practice well and over a long time span. Drawing on that knowledge, you are well placed to spot the red flags that may signal depression in an adolescent patient.

Risk factors for the disorder are well known: a previous episode of depression, a family history of depression, the presence of other psychiatric disorders such as anxiety or attention deficit hyperactivity disorder (ADHD), substance abuse, or life stressors such as bereavement, abuse, or divorce. Teens with depression may complain of emotional problems, or turn up with repeated somatic complaints—headaches, stomach aches, fatigue—that have no apparent physiologic explanation. Their responses to general questions, such as “How is your mood?” or “Have you been sad?” may be worrisome. Or they may screen positive on self-report checklists such as the Beck Depression Inventory (BDI) or the Kutcher Adolescent Depression Scale (KADS), available for download at www.cprf.ca/education/Openmind2006/KADS11.pdf and free for use with permission.^9,10

Routine screening of all adolescents for depression may be feasible, but the US Preventive Services Task Force concluded in 2002 that the evidence was insufficient to recommend for or against the practice.^7,11,12 Expert opinion suggests that among adolescents at elevated risk for depression, depression checklists are useful during well-child and urgent care visits. However, families will likely find general questions more acceptable during acute care visits.¹⁰

“SIGECAPS” mnemonic can help as you evaluate the patient

When you suspect depression, take a detailed history. The diagnostic criteria for depression given in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) are shown in TABLE 1 .^7,10,13 Bear in mind, however, that adolescents who do not meet the full criteria may still be quite impaired and in need of help. The SIGECAPS mnemonic (sleep, interest, guilt, energy, concentration, appetite changes, psychomotor agitation or retardation, suicidality) can help you recall the neurovegetative symptoms in the depression criteria.

Ask about bereavement, manic symptoms (eg, feeling irritable/giddy/silly, hyperactive, racing thoughts), substance use, and life stressors. Ask, too, whether the teen has been treated for mental health problems in the past, and if there is any history of physical or sexual abuse or a family history of mental illness. Because depression is often comorbid with other conditions, you should also inquire about other psychiatric disorders, such as ADHD and anxiety disorders.

The next step. When risk factors or checklists alert you to the possibility of depression, the next step is a more formal evaluation. Because teens and parents often feel uncomfortable disclosing information in the presence of the other, separate interviews are a good idea. Information crucial to the diagnosis may be available only from the adolescent or only from the parent or caregiver, and then only if they are interviewed separately.⁷

Parents may—or may not—pick up on their child’s depression. On the one hand, parents will often have important clues to their child’s diagnosis, such as recent withdrawal from social or extracurricular activities. On the other hand, they may attribute their teen’s behavior to normal adolescent moodiness. Or they might not recognize their teenager’s depression because teens don’t need to be “sad” to be depressed. Sometimes irritability is the major symptom in a depressed teen. (See “How teenage depression is different from that of adults” on page 188.)

Further compounding matters: Since depression is an internalizing disorder, teens may not share their innermost thoughts and emotions with their parents.

TABLE 1
Diagnostic criteria for major depressive episode (DSM-IV-TR)

Is it MDD, or something else?

Although most of the literature on depression is focused on MDD, you should be aware that there are many subtypes of depression, including dysthymia (in which patients have longstanding depressive symptoms but with less functional impairment than major depression) and adjustment disorder (in which patients develop depressive symptoms in response to an acute stressor). As mentioned above, physicians should also assess for psychiatric disorders that are commonly comorbid with depression, because their presence can affect management. These include anxiety disorders, ADHD, eating disorders, and substance abuse.

Ruling out alternative diagnoses. In assessing potentially depressed teenagers like Jane, ruling out conditions with similar symptoms is essential. Medical conditions to be considered in the differential diagnosis are anemia, malignancies, hypothyroidism, and mononucleosis—as well as other viral conditions. There is, however, no evidence to support routine lab testing (including for hypothyroidism) of adolescent patients. Laboratory and other diagnostic evaluation should, instead, be guided by history and targeted physical exam. TABLE 2 presents common medical causes of symptoms of depression that must be considered in the differential diagnosis.

Consider bipolar disorder. Depressive symptoms may also be part of a cycling mood disorder, such as bipolar disorder. In fact, most teens with bipolar disorder will first present with depressive symptoms. Adolescents with depression as part of a bipolar disorder are more likely to have adverse effects with antidepressants than are teens with depression alone. In order to adequately rule out bipolar depression, ask about:

• rapid onset of depressive symptoms: “She just woke up one day and couldn’t stop crying,” for instance
• psychotic symptoms
• family history of bipolar disorder, especially in first-degree relatives
• previous symptoms of mania while on antidepressant treatment (eg, hyperactive, rapid speech, decreased need for sleep).

If a patient has these symptoms or a history of bipolar disorder, refer her or him for a mental health consultation before starting antidepressant treatment.

TABLE 2
Is a medical cause to blame for those symptoms of depression?

Help in classifying the severity of depression

The severity of depression can vary considerably from one patient to another, and distinguishing mild, moderate, and severe depression has significant implications for treatment. Guidelines for grading depression severity are given in TABLE 3 . A common way to classify the severity of a depressive episode is to count the number of symptoms the teenager is displaying.⁷ If all 9 symptoms in the DSM-IV-TR criteria are present, the depression would be classified as severe. But even with fewer symptoms, depression should be considered severe if the teenager is suicidal (has a specific suicide plan, a clear intent, or has made a recent attempt); has psychotic symptoms; or functioning is severely impaired (eg, patient is unable to go to school). The Diagnostic and Statistical Manual of Mental Disorders: Primary Care Version (DSM-PC) is also a useful resource for distinguishing between transient depressive responses and depressive disorders.

TABLE 3
Grading the severity of depressive episodes

Ask yourself: Is this teenager impaired?

Symptoms, in themselves, are not enough to clinch the diagnosis. The fundamental question is whether the symptoms prevent your patient from normal functioning. To judge the extent of a patient’s impairment, you need to assess overall functioning and ask about school, home, friends, and leisure activities. Impairment can be determined by asking the patient and parents the simple questions that every family physician is familiar with:

• How is Jane doing in school? Have her grades slipped lately?
• How is life at home? Does Jane’s mood affect family relationships?
• Does Jane have good friends she can talk to?
• Has her mood affected her ability to maintain friendships?
• What does Jane do for fun? Has she been doing those things lately?

First and foremost, keep your patient safe. Even if you can’t do a complete assessment, your evaluation must at least include the determination of acute risk of harm, either from self-inflicted injury or from impaired judgment. At minimum, assess for suicidality, self-injurious behavior, altered sensorium, substance use, and access to firearms.⁷ Again, this can be aided by the teen’s answers to symptom checklists.

CORRESPONDENCE
Amy Cheung, MD, 33 Russell Street, 3rd Floor Tower, Toronto, Ontario, Canada MSS 2S1; dramy.cheung@gmail.com

You’ve known Jane since infancy. Now she’s 15 and in your office for her yearly checkup. As she comes into the exam room, you notice she’s gained a lot of weight since you saw her a year ago. She’s also missing the energy and sparkle that have always been such an engaging part of her personality. When you trot out your usual questions for teens—How’s school? Keeping up your grades? Going out for a team?—her answers are disquieting. School’s dull, her grades have gone downhill, and she’s dropped out of gymnastics. Her mother says Jane is irritable and sleeping a lot, and that worries her.

Could Jane be going through a bout of clinical depression?

Teen depression: Common, and commonly untreated

In North America, about 9% of all teenagers meet the criteria for depression at any given time, and prevalence rates in primary care are very likely higher.¹ One study in the 1990s found approximately 28% of teens presenting to a primary care office met criteria for depression.²

Although adolescents with depression frequently seek care in the primary care setting, most are not identified or treated because of any number of barriers.^3,4 First, mental illness continues to be highly stigmatized. As a result, many troubled teens (and parents of these teens) do not seek help.⁴ Second, mental health professionals trained to treat adolescents are in short supply, and most family physicians and other primary care clinicians feel inadequately trained, supported, or reimbursed for the management of this disorder.⁵ Third, the controversy over the safety and efficacy of antidepressants in the pediatric population has created an additional barrier to care.

In addition, while clinical guidelines for diagnosing and treating adolescent depression have been developed for specialty care settings,⁶ they are not easily transferred to primary care because of the significant differences between the primary and specialty care settings. Recognizing this gap in clinical guidance, a group of researchers and clinicians (including the authors of this report) from the United States and Canada established a collaborative to formulate primary care guidelines for adolescent depression (GuideLines for Adolescent Depression in Primary Care, or GLAD-PC). Details about the collaborative’s methods and recommendations were published in Pediatrics in 2007.^7,8 The accompanying clinician toolkit is available at www.gladpc.org.

This review summarizes the collaborative’s key findings and recommendations and includes evidence from additional research published since the completion of GLAD-PC in 2007. For simplicity’s sake, we use the term “depression” to refer to what is more formally known as major depressive disorder (MDD).

Red flags that you are well positioned to spot

As a family physician, you have the advantage of knowing the families in your practice well and over a long time span. Drawing on that knowledge, you are well placed to spot the red flags that may signal depression in an adolescent patient.

Risk factors for the disorder are well known: a previous episode of depression, a family history of depression, the presence of other psychiatric disorders such as anxiety or attention deficit hyperactivity disorder (ADHD), substance abuse, or life stressors such as bereavement, abuse, or divorce. Teens with depression may complain of emotional problems, or turn up with repeated somatic complaints—headaches, stomach aches, fatigue—that have no apparent physiologic explanation. Their responses to general questions, such as “How is your mood?” or “Have you been sad?” may be worrisome. Or they may screen positive on self-report checklists such as the Beck Depression Inventory (BDI) or the Kutcher Adolescent Depression Scale (KADS), available for download at www.cprf.ca/education/Openmind2006/KADS11.pdf and free for use with permission.^9,10

Routine screening of all adolescents for depression may be feasible, but the US Preventive Services Task Force concluded in 2002 that the evidence was insufficient to recommend for or against the practice.^7,11,12 Expert opinion suggests that among adolescents at elevated risk for depression, depression checklists are useful during well-child and urgent care visits. However, families will likely find general questions more acceptable during acute care visits.¹⁰

“SIGECAPS” mnemonic can help as you evaluate the patient

When you suspect depression, take a detailed history. The diagnostic criteria for depression given in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) are shown in TABLE 1 .^7,10,13 Bear in mind, however, that adolescents who do not meet the full criteria may still be quite impaired and in need of help. The SIGECAPS mnemonic (sleep, interest, guilt, energy, concentration, appetite changes, psychomotor agitation or retardation, suicidality) can help you recall the neurovegetative symptoms in the depression criteria.

Ask about bereavement, manic symptoms (eg, feeling irritable/giddy/silly, hyperactive, racing thoughts), substance use, and life stressors. Ask, too, whether the teen has been treated for mental health problems in the past, and if there is any history of physical or sexual abuse or a family history of mental illness. Because depression is often comorbid with other conditions, you should also inquire about other psychiatric disorders, such as ADHD and anxiety disorders.

The next step. When risk factors or checklists alert you to the possibility of depression, the next step is a more formal evaluation. Because teens and parents often feel uncomfortable disclosing information in the presence of the other, separate interviews are a good idea. Information crucial to the diagnosis may be available only from the adolescent or only from the parent or caregiver, and then only if they are interviewed separately.⁷

Parents may—or may not—pick up on their child’s depression. On the one hand, parents will often have important clues to their child’s diagnosis, such as recent withdrawal from social or extracurricular activities. On the other hand, they may attribute their teen’s behavior to normal adolescent moodiness. Or they might not recognize their teenager’s depression because teens don’t need to be “sad” to be depressed. Sometimes irritability is the major symptom in a depressed teen. (See “How teenage depression is different from that of adults” on page 188.)

Further compounding matters: Since depression is an internalizing disorder, teens may not share their innermost thoughts and emotions with their parents.

TABLE 1
Diagnostic criteria for major depressive episode (DSM-IV-TR)

Is it MDD, or something else?

Although most of the literature on depression is focused on MDD, you should be aware that there are many subtypes of depression, including dysthymia (in which patients have longstanding depressive symptoms but with less functional impairment than major depression) and adjustment disorder (in which patients develop depressive symptoms in response to an acute stressor). As mentioned above, physicians should also assess for psychiatric disorders that are commonly comorbid with depression, because their presence can affect management. These include anxiety disorders, ADHD, eating disorders, and substance abuse.

Ruling out alternative diagnoses. In assessing potentially depressed teenagers like Jane, ruling out conditions with similar symptoms is essential. Medical conditions to be considered in the differential diagnosis are anemia, malignancies, hypothyroidism, and mononucleosis—as well as other viral conditions. There is, however, no evidence to support routine lab testing (including for hypothyroidism) of adolescent patients. Laboratory and other diagnostic evaluation should, instead, be guided by history and targeted physical exam. TABLE 2 presents common medical causes of symptoms of depression that must be considered in the differential diagnosis.

Consider bipolar disorder. Depressive symptoms may also be part of a cycling mood disorder, such as bipolar disorder. In fact, most teens with bipolar disorder will first present with depressive symptoms. Adolescents with depression as part of a bipolar disorder are more likely to have adverse effects with antidepressants than are teens with depression alone. In order to adequately rule out bipolar depression, ask about:

• rapid onset of depressive symptoms: “She just woke up one day and couldn’t stop crying,” for instance
• psychotic symptoms
• family history of bipolar disorder, especially in first-degree relatives
• previous symptoms of mania while on antidepressant treatment (eg, hyperactive, rapid speech, decreased need for sleep).

If a patient has these symptoms or a history of bipolar disorder, refer her or him for a mental health consultation before starting antidepressant treatment.

TABLE 2
Is a medical cause to blame for those symptoms of depression?

Help in classifying the severity of depression

The severity of depression can vary considerably from one patient to another, and distinguishing mild, moderate, and severe depression has significant implications for treatment. Guidelines for grading depression severity are given in TABLE 3 . A common way to classify the severity of a depressive episode is to count the number of symptoms the teenager is displaying.⁷ If all 9 symptoms in the DSM-IV-TR criteria are present, the depression would be classified as severe. But even with fewer symptoms, depression should be considered severe if the teenager is suicidal (has a specific suicide plan, a clear intent, or has made a recent attempt); has psychotic symptoms; or functioning is severely impaired (eg, patient is unable to go to school). The Diagnostic and Statistical Manual of Mental Disorders: Primary Care Version (DSM-PC) is also a useful resource for distinguishing between transient depressive responses and depressive disorders.

TABLE 3
Grading the severity of depressive episodes

Ask yourself: Is this teenager impaired?

Symptoms, in themselves, are not enough to clinch the diagnosis. The fundamental question is whether the symptoms prevent your patient from normal functioning. To judge the extent of a patient’s impairment, you need to assess overall functioning and ask about school, home, friends, and leisure activities. Impairment can be determined by asking the patient and parents the simple questions that every family physician is familiar with:

• How is Jane doing in school? Have her grades slipped lately?
• How is life at home? Does Jane’s mood affect family relationships?
• Does Jane have good friends she can talk to?
• Has her mood affected her ability to maintain friendships?
• What does Jane do for fun? Has she been doing those things lately?

First and foremost, keep your patient safe. Even if you can’t do a complete assessment, your evaluation must at least include the determination of acute risk of harm, either from self-inflicted injury or from impaired judgment. At minimum, assess for suicidality, self-injurious behavior, altered sensorium, substance use, and access to firearms.⁷ Again, this can be aided by the teen’s answers to symptom checklists.

CORRESPONDENCE
Amy Cheung, MD, 33 Russell Street, 3rd Floor Tower, Toronto, Ontario, Canada MSS 2S1; dramy.cheung@gmail.com

You’ve known Jane since infancy. Now she’s 15 and in your office for her yearly checkup. As she comes into the exam room, you notice she’s gained a lot of weight since you saw her a year ago. She’s also missing the energy and sparkle that have always been such an engaging part of her personality. When you trot out your usual questions for teens—How’s school? Keeping up your grades? Going out for a team?—her answers are disquieting. School’s dull, her grades have gone downhill, and she’s dropped out of gymnastics. Her mother says Jane is irritable and sleeping a lot, and that worries her.

Could Jane be going through a bout of clinical depression?

Teen depression: Common, and commonly untreated

In North America, about 9% of all teenagers meet the criteria for depression at any given time, and prevalence rates in primary care are very likely higher.¹ One study in the 1990s found approximately 28% of teens presenting to a primary care office met criteria for depression.²

Although adolescents with depression frequently seek care in the primary care setting, most are not identified or treated because of any number of barriers.^3,4 First, mental illness continues to be highly stigmatized. As a result, many troubled teens (and parents of these teens) do not seek help.⁴ Second, mental health professionals trained to treat adolescents are in short supply, and most family physicians and other primary care clinicians feel inadequately trained, supported, or reimbursed for the management of this disorder.⁵ Third, the controversy over the safety and efficacy of antidepressants in the pediatric population has created an additional barrier to care.

In addition, while clinical guidelines for diagnosing and treating adolescent depression have been developed for specialty care settings,⁶ they are not easily transferred to primary care because of the significant differences between the primary and specialty care settings. Recognizing this gap in clinical guidance, a group of researchers and clinicians (including the authors of this report) from the United States and Canada established a collaborative to formulate primary care guidelines for adolescent depression (GuideLines for Adolescent Depression in Primary Care, or GLAD-PC). Details about the collaborative’s methods and recommendations were published in Pediatrics in 2007.^7,8 The accompanying clinician toolkit is available at www.gladpc.org.

This review summarizes the collaborative’s key findings and recommendations and includes evidence from additional research published since the completion of GLAD-PC in 2007. For simplicity’s sake, we use the term “depression” to refer to what is more formally known as major depressive disorder (MDD).

Red flags that you are well positioned to spot

As a family physician, you have the advantage of knowing the families in your practice well and over a long time span. Drawing on that knowledge, you are well placed to spot the red flags that may signal depression in an adolescent patient.

Risk factors for the disorder are well known: a previous episode of depression, a family history of depression, the presence of other psychiatric disorders such as anxiety or attention deficit hyperactivity disorder (ADHD), substance abuse, or life stressors such as bereavement, abuse, or divorce. Teens with depression may complain of emotional problems, or turn up with repeated somatic complaints—headaches, stomach aches, fatigue—that have no apparent physiologic explanation. Their responses to general questions, such as “How is your mood?” or “Have you been sad?” may be worrisome. Or they may screen positive on self-report checklists such as the Beck Depression Inventory (BDI) or the Kutcher Adolescent Depression Scale (KADS), available for download at www.cprf.ca/education/Openmind2006/KADS11.pdf and free for use with permission.^9,10

Routine screening of all adolescents for depression may be feasible, but the US Preventive Services Task Force concluded in 2002 that the evidence was insufficient to recommend for or against the practice.^7,11,12 Expert opinion suggests that among adolescents at elevated risk for depression, depression checklists are useful during well-child and urgent care visits. However, families will likely find general questions more acceptable during acute care visits.¹⁰

“SIGECAPS” mnemonic can help as you evaluate the patient

When you suspect depression, take a detailed history. The diagnostic criteria for depression given in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) are shown in TABLE 1 .^7,10,13 Bear in mind, however, that adolescents who do not meet the full criteria may still be quite impaired and in need of help. The SIGECAPS mnemonic (sleep, interest, guilt, energy, concentration, appetite changes, psychomotor agitation or retardation, suicidality) can help you recall the neurovegetative symptoms in the depression criteria.

Ask about bereavement, manic symptoms (eg, feeling irritable/giddy/silly, hyperactive, racing thoughts), substance use, and life stressors. Ask, too, whether the teen has been treated for mental health problems in the past, and if there is any history of physical or sexual abuse or a family history of mental illness. Because depression is often comorbid with other conditions, you should also inquire about other psychiatric disorders, such as ADHD and anxiety disorders.

The next step. When risk factors or checklists alert you to the possibility of depression, the next step is a more formal evaluation. Because teens and parents often feel uncomfortable disclosing information in the presence of the other, separate interviews are a good idea. Information crucial to the diagnosis may be available only from the adolescent or only from the parent or caregiver, and then only if they are interviewed separately.⁷

Parents may—or may not—pick up on their child’s depression. On the one hand, parents will often have important clues to their child’s diagnosis, such as recent withdrawal from social or extracurricular activities. On the other hand, they may attribute their teen’s behavior to normal adolescent moodiness. Or they might not recognize their teenager’s depression because teens don’t need to be “sad” to be depressed. Sometimes irritability is the major symptom in a depressed teen. (See “How teenage depression is different from that of adults” on page 188.)

Further compounding matters: Since depression is an internalizing disorder, teens may not share their innermost thoughts and emotions with their parents.

TABLE 1
Diagnostic criteria for major depressive episode (DSM-IV-TR)

Is it MDD, or something else?

Although most of the literature on depression is focused on MDD, you should be aware that there are many subtypes of depression, including dysthymia (in which patients have longstanding depressive symptoms but with less functional impairment than major depression) and adjustment disorder (in which patients develop depressive symptoms in response to an acute stressor). As mentioned above, physicians should also assess for psychiatric disorders that are commonly comorbid with depression, because their presence can affect management. These include anxiety disorders, ADHD, eating disorders, and substance abuse.

Ruling out alternative diagnoses. In assessing potentially depressed teenagers like Jane, ruling out conditions with similar symptoms is essential. Medical conditions to be considered in the differential diagnosis are anemia, malignancies, hypothyroidism, and mononucleosis—as well as other viral conditions. There is, however, no evidence to support routine lab testing (including for hypothyroidism) of adolescent patients. Laboratory and other diagnostic evaluation should, instead, be guided by history and targeted physical exam. TABLE 2 presents common medical causes of symptoms of depression that must be considered in the differential diagnosis.

Consider bipolar disorder. Depressive symptoms may also be part of a cycling mood disorder, such as bipolar disorder. In fact, most teens with bipolar disorder will first present with depressive symptoms. Adolescents with depression as part of a bipolar disorder are more likely to have adverse effects with antidepressants than are teens with depression alone. In order to adequately rule out bipolar depression, ask about:

• rapid onset of depressive symptoms: “She just woke up one day and couldn’t stop crying,” for instance
• psychotic symptoms
• family history of bipolar disorder, especially in first-degree relatives
• previous symptoms of mania while on antidepressant treatment (eg, hyperactive, rapid speech, decreased need for sleep).

If a patient has these symptoms or a history of bipolar disorder, refer her or him for a mental health consultation before starting antidepressant treatment.

TABLE 2
Is a medical cause to blame for those symptoms of depression?

Help in classifying the severity of depression

The severity of depression can vary considerably from one patient to another, and distinguishing mild, moderate, and severe depression has significant implications for treatment. Guidelines for grading depression severity are given in TABLE 3 . A common way to classify the severity of a depressive episode is to count the number of symptoms the teenager is displaying.⁷ If all 9 symptoms in the DSM-IV-TR criteria are present, the depression would be classified as severe. But even with fewer symptoms, depression should be considered severe if the teenager is suicidal (has a specific suicide plan, a clear intent, or has made a recent attempt); has psychotic symptoms; or functioning is severely impaired (eg, patient is unable to go to school). The Diagnostic and Statistical Manual of Mental Disorders: Primary Care Version (DSM-PC) is also a useful resource for distinguishing between transient depressive responses and depressive disorders.

TABLE 3
Grading the severity of depressive episodes

Ask yourself: Is this teenager impaired?

Symptoms, in themselves, are not enough to clinch the diagnosis. The fundamental question is whether the symptoms prevent your patient from normal functioning. To judge the extent of a patient’s impairment, you need to assess overall functioning and ask about school, home, friends, and leisure activities. Impairment can be determined by asking the patient and parents the simple questions that every family physician is familiar with:

• How is Jane doing in school? Have her grades slipped lately?
• How is life at home? Does Jane’s mood affect family relationships?
• Does Jane have good friends she can talk to?
• Has her mood affected her ability to maintain friendships?
• What does Jane do for fun? Has she been doing those things lately?

First and foremost, keep your patient safe. Even if you can’t do a complete assessment, your evaluation must at least include the determination of acute risk of harm, either from self-inflicted injury or from impaired judgment. At minimum, assess for suicidality, self-injurious behavior, altered sensorium, substance use, and access to firearms.⁷ Again, this can be aided by the teen’s answers to symptom checklists.

CORRESPONDENCE
Amy Cheung, MD, 33 Russell Street, 3rd Floor Tower, Toronto, Ontario, Canada MSS 2S1; dramy.cheung@gmail.com