depression management in primary care Susan Meyer, CPNP, PMHS - - PowerPoint PPT Presentation

depression

management in primary care Susan Meyer, CPNP, PMHS

mental health disorder seen in children

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CDC

depression

• common and serious medical illness
• negatively affects how a person feels, thinks & acts
• treatable
• causes feelings of sadness and/or a loss of interest in

activities once enjoyed

• can lead to a variety of emotional and physical problems
• can decrease a person’s ability to function at work and at

home.

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mental health access issues

Early intervention can influence outcomes for the child, family and society Delayed care can increase school problems, family stress and overall health problems into adulthood

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looking to PCP for providers

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GLAD – PC Tool Kit

• Guidelines for Adolescent Depression in Primary Care
• Materials organized to help screen, assess and manage depression

in primary care

• published in the March 2018 volume of Pediatrics
• contributors from American Academy of Pediatrics, the American

Psychiatric Association, the American Academy of Child and Adolescent Psychiatry

GLAD – PC Tool Kit

• I. GLAD-PC Guidelines
• II. General Psychosocial

Screens

• III. Screening & Diagnostic

Aids

• IV. Treatment Information for

Providers

• V. Treatment Referrals &

Follow up

• VI. Speaking with

Adolescents & Parents

• VII. Educational Materials for

Adolescents

• VIII. Educational Materials

for Parents

• IX. Billing
• X. Organizational Change

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Screening & Diagnostic Aids

• The Whole Child Assessment (WCA)
• Strengths and Difficulties Questionnaire (SDQ)
• Pediatric Symptom Checklist-35 (PSC-35)
• Youth Pediatric Symptom Checklist (Y-PSC-35)
• Pediatric Symptom Checklist-17 (PSC-17)
• Pediatric Symptom Checklist-17, Youth (PSC 17-Y)
• Columbia Depression Scale (Teen & Parent)
• Kutcher Adolescent Depression Scale – 6-item
• PHQ-9 Modified for Teens in multiple languages
• Clinician Assessment of Functioning Children’s Global

Assessment Scale (C-GAS)

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Decision tree

Assessment Non-Crisis Mild (Therapy) Moderate (Therapy + Meds) Severe or Crisis Refer

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Evidence-based Pharmacotherapy

• SSRIs are the medication of choice
• Block serotonin reuptake
• Lower side effect profile compared to SNRIs, TCAs, NDRI

and MAOIs

• Black box warnings
• Start low and go slow
• May take 2-8 weeks to take effect
• Psychotherapy is an essential part of treatment

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Black box warnings

• First implemented in 2004 by the FDA to carefully monitor

patients for activation of suicidal ideation with start of antidepressants.

• Black box warning first caused a decrease in patients
• btaining treatment due to stigma.

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Why suicide assessment?

• Everyday in the U.S. >5,000 7th-12th graders attempt

suicide

• 6,200 Americans 15-24 die each year by suicide
• 2nd leading cause of death for ages 15-34 in the state of

Ohio

• 11th leading cause of death in the state of Ohio

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Warning Signs

• Talking
• Direct vs. Indirect Statements
• Change in behaviors
• Withdrawn
• Giving away possessions
• Alcohol and drug use
• Change in mood
• Depression
• Hopelessness
• Anxiety

Risk Factors

• Health Factors
• Mental Health Disorders
• Environmental Factors
• Living situation
• Historical Factors
• History of previous suicidal

attempts

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suicide assessment

Suicide assessment

• Access suicidal ideations, plan, intent at time of initial

assessment and at every follow up appointment.

• If possible, discuss safety plan and identify a family member,

peer or teacher patient can reach out to if suicidal thoughts worsen or occur.

• National Suicide Prevention Lifeline
• 1-800-273- TALK (8255)
• Crisis Text line
• Text TALK to 741741

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starting medication

Medication Starting Dose* Increments Effective Dose Maximum Dosage Not to Be Used With Common Adverse Effects RCT Evidence for Efficacy

First Line Fluoxetine 10 mg po qd 10-20 mg 20 mg 60 mg MAOIs*** Headaches, GI upset, insomnia, agitation, anxiety Y** Second Line Escitalopram (first-line: 12 and older) 5 mg po qd 5 mg 10-20 mg 20 mg MAOIs*** Headaches, GI upset, insomnia Y** Citaloprama 10 mg po qd 10 mg 20 mg 40 mg MAOIs*** Headaches, GI upset, insomnia Y Sertraline 25 mg po qd 12.5-25 mg 100 mg 200 mg MAOIs*** Headaches, GI upset Y

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SSRI Dosing and Adverse Effects *Younger adolescents should be started on lower doses **FDA approved ***MAOI, monoamine oxidase inhibitor aClinicians should consider an EKG given the warning

• f cardiac side effects

with improvement

• Titrate dose at 2 to 6 weeks. If starting doses low and no

response at 2 weeks, can increase dose but then give dose time to take effect before another dose increase

• Goal is complete remission and prevention of relapses
• Once symptoms are gone, continue treatment for 1 year

with the 1st episode

• Subsequent episodes may need indefinite treatment

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If no improvement

• If partial responder, consider increasing dose, switching to

another agent or adding an appropriate augmenting agent

• Consider psychotherapy
• Consider referral to psychiatry

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Common

• GI distress (nausea,

diarrhea, constipation)

• Dizziness
• Headache
• Irritability
• Disinhibition

Severe

• Serotonin Syndrome
• Bleeding disorders
• Treatment-emergent

activation syndrome (TEAS)

• Hypomania
• Agitation
• Anxiety
• Hostility/aggression
• Insomnia
• Suicidality (black box warning)

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side effects

what to do about side effects

• Mild: Wait, wait, wait for 2-7 days to see if side effects are

transient.

• If side effects are persistent but tolerable: continue dose
• Moderate: Reduce the dose or change the dosing schedule

for symptoms such as sedation

• Severe: Discontinue medication

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fluoxetine (Prozac)

• Consider first line for low energy depression
• Morning dosing
• May want to avoid in patient who are agitated, highly

reactive

• Long half life, self weaning
• FDA Approved for
• Major depressive disorder (8+ years)
• Obsessive Compulsive Disorder (7+ years)
• Premenstrual dysphoric disorder
• Panic Disorder
• Bulimia nervosa

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Escitalopram (Lexapro)

• May be a better fit for depression with anxiety
• FDA Approved for
• Major depressive disorder (12+ years)
• Generalized anxiety disorder
• Decreasing dose by 50% to wean is usually tolerated

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Citalopram (Celexa)

• FDA Approved for
• Depression
• Can cause sleepiness, partial antihistamine effect
• May lose weight or gain weight
• Keep dose below 40 mg to avoid cardiac side effects, may

want to monitor EKG

• Possible hyponatremia

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Sertraline (Zoloft)

• FDA Approved for
• Major depressive disorder (6+ years)
• Obsessive compulsive disorder (6+ years)
• Premenstrual dysphoric disorder
• Panic disorder
• Social anxiety disorder
• Morning dosing unless sleepiness is noted
• Young children may start dose at 12.5 mg or lower
• Dilute liquid form in water, lemon-lime soda, OJ
• More anxious patients generally need lower starting dose

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Venlafaxine (Effexor XR) SNRI

• FDA Approved for
• Depression
• Generalized anxiety disorder
• Social anxiety disorder
• Panic disorder
• Consider offering after two failed SSRI attempts
• Most often used in XR form due to short duration of action
• Withdrawal is more common, may need long slow titration to

stop medication

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references

• https://www.cdc.gov/childrensmentalhealth/data.html#ref
• US Department of Health and Human Services Health

Resources and Services Administration & Maternal and Child Health Bureau. Mental health: A report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, and National Institutes of Health, National Institute of Mental Health; 1999.

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references

• www.gladpc.org
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3744276/

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