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 CDC 2

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. 3

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 4

looking to PCP for providers 5

GLAD – PC Tool Kit • Guidelines for Adolescent Depression in Primary Care o Materials organized to help screen, assess and manage depression in primary care o published in the March 2018 volume of Pediatrics o 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 • VI. Speaking with Adolescents & Parents • II. General Psychosocial • VII. Educational Materials for Screens Adolescents • III. Screening & Diagnostic • VIII. Educational Materials Aids for Parents • IV. Treatment Information for • IX. Billing Providers • V. Treatment Referrals & • X. Organizational Change Follow up 7

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) 8

Decision tree Mild (Therapy) Non-Crisis Moderate (Therapy + Assessment Meds) Severe or Crisis Refer 9

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 10

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 obtaining treatment due to stigma. 11

Why suicide assessment? • Everyday in the U.S. >5,000 7 th -12 th graders attempt suicide • 6,200 Americans 15-24 die each year by suicide • 2 nd leading cause of death for ages 15-34 in the state of Ohio • 11 th leading cause of death in the state of Ohio 12

suicide assessment Warning Signs Risk Factors • Talking • Health Factors o Direct vs. Indirect Statements o Mental Health Disorders • Change in behaviors • Environmental Factors o Withdrawn o Living situation o Giving away possessions • Historical Factors o Alcohol and drug use o History of previous suicidal • Change in mood attempts o Depression o Hopelessness o Anxiety 13

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 o 1-800-273- TALK (8255) • Crisis Text line o Text TALK to 741741 14

starting medication SSRI Dosing and Adverse Effects RCT Not to Be Common Evidence Medication Starting Increments Effective Maximum Used With Adverse for Dose* Dose Dosage Effects Efficacy Headaches, GI upset, insomnia, First Line agitation, anxiety 10 mg po Fluoxetine 10-20 mg 20 mg 60 mg MAOIs*** Y** qd Escitalopram Headaches, GI 5 mg po qd (first-line: 5 mg 10-20 mg 20 mg MAOIs*** Y** upset, insomnia 12 and older) Second Line Headaches, GI 10 mg po upset, insomnia Citalopram a 10 mg 20 mg 40 mg MAOIs*** Y qd 25 mg po Headaches, GI qd upset Sertraline 12.5-25 mg 100 mg 200 mg MAOIs*** Y *Younger adolescents should be started on lower doses **FDA approved ***MAOI, monoamine oxidase inhibitor aClinicians should consider an EKG given the warning of cardiac side effects 15

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 1 st episode • Subsequent episodes may need indefinite treatment 16

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 17

side effects Common Severe • GI distress (nausea, • Serotonin Syndrome diarrhea, constipation) • Bleeding disorders • Dizziness • Treatment-emergent • Headache activation syndrome (TEAS) o Hypomania • Irritability o Agitation • Disinhibition o Anxiety o Hostility/aggression o Insomnia o Suicidality (black box warning) 18

what to do about side effects • Mild: Wait, wait, wait for 2-7 days to see if side effects are transient. o 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 19

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 o Major depressive disorder (8+ years) o Obsessive Compulsive Disorder (7+ years) o Premenstrual dysphoric disorder o Panic Disorder o Bulimia nervosa 20

Escitalopram (Lexapro) • May be a better fit for depression with anxiety • FDA Approved for o Major depressive disorder (12+ years) o Generalized anxiety disorder • Decreasing dose by 50% to wean is usually tolerated 21

Citalopram (Celexa) • FDA Approved for o 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 22

Sertraline (Zoloft) • FDA Approved for o Major depressive disorder (6+ years) o Obsessive compulsive disorder (6+ years) o Premenstrual dysphoric disorder o Panic disorder o 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 23

Venlafaxine (Effexor XR) SNRI • FDA Approved for o Depression o Generalized anxiety disorder o Social anxiety disorder o 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 24

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. 25

references • www.gladpc.org • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3744276/ 26