“My son won’t talk to us, yells at me and is missing school,” says the mother of a 16-year-old boy.
“Can you test my child for mono?” the parent of a 17-year-old boy asks. “He’s sleeping all the time and says he doesn’t have the energy to get out of bed.”
“I think the world would be a better place if I had never been born,” a 14-year-old girl says.
Adolescents suffering from depression may present to their pediatrician with varied chief complaints, some of which are much less obvious than others. As a result, major depressive disorder (MDD) is not always picked up in primary care.
Even when depression is suspected, many pediatricians hesitate to make the diagnosis without mental health input. And even when a diagnosis is made, many feel at a loss, given the barriers to accessing the mental health system and lack of training on treatment of MDD. As one pediatrician said: “I sought training in mental health because I got sick of hearing the families’ stories and feeling the only thing I could do was provide tissues.”
To fill that void, the Academy has endorsed the updated version of Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment and Initial Management, and Part II. Treatment and Ongoing Management. They are available at https://doi.org/10.1542/peds.2017-4081 and https://doi.org/10.1542/peds.2017-4082 and will be published in the March issue of Pediatrics.
It has been over 10 years since the initial publication and AAP endorsement of GLAD-PC, yet many primary care pediatricians still are not practicing evidence-based management of adolescent depression. Some even say it is not in their scope of practice despite the AAP endorsement.
To address those issues, Part I of the updated guidelines includes a new section on preparing one’s practice to manage adolescent depression. The guidelines suggest getting staff buy-in, training providers and learning how to access specialty consultation through statewide programs. The guidelines discuss different theories and models of learning that can help change the way pediatricians practice, improving their ability to provide mental health care to young patients.
Another major update to Part I is the endorsement of universal adolescent depression screening for those ages 12 and over using a formal depression self-report tool. The prior guidelines supported systematically identifying depression risk factors but stopped short of recommending universal screening.
Since the last iteration of the guidelines, the U.S. Preventive Services Task Force has twice endorsed universal adolescent depression screening, and the Academy also supports universal screening for those 12 and over. The guidelines summarize the evidence for screening and the use of formal tools as well as research gaps.
An expanded algorithm in Part I emphasizes the many ways that an adolescent may enter into the depression protocol. Some patients may be discovered through screening at a health maintenance visit, while others will be detected only if primary care providers remain vigilant for depression when youths present with chronic somatic complaints, other behavioral chief complaints or risk factors for adolescent depression such as a family history of depression, trauma, substance use or psychosocial adversity.
Part I and its algorithm detail the steps after the initial screening process, which should empower pediatricians to diagnose depression in their patients.
Latest evidence in management
Part II of the guidelines, which focuses on treatment and ongoing management, has an expanded section on integrated behavioral health and collaborative care models. A new recommendation emphasizes the need to rework the administrative aspects of one’s practice to reflect the best practices in integrated and collaborative care.
Once again, the guidelines recommend active support and monitoring in primary care for those with mild depression, providing a clear role for the pediatrician. The guidelines also review the latest evidence in medication and psychotherapy treatment for adolescents with moderate to severe depression. Selective serotonin reuptake inhibitors (SSRIs) remain the first-choice antidepressant in adolescent MDD, and cognitive behavioral therapy (CBT) and interpersonal psychotherapy for adolescents (IPT-A) are the psychotherapy treatments with the most evidence.
Suggestions as to when to treat in primary care and when to refer also are provided. Of utmost importance are suggestions on how to negotiate roles and responsibilities between primary care and mental health.
Like the original GLAD-PC guidelines, the revised guidelines used evidence- and consensus-based methodology and are a result of collaboration among numerous stakeholders, including clinicians, researchers, families and youths.
- Prepare your practice by attending mental health trainings.
- Learn what statewide and/or local psychiatric consultation for primary care programs are available.
- Implement universal depression screening at annual health maintenance visits with a formal self-report tool for those 12 years and older.
- Implement targeted screening with a formal self-report tool of all adolescents with depression risk factors.
- Interview adolescents alone.
- Involve families in the depression assessment.
- Use criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition to make a formal diagnosis.
- Devise a safety plan with youths and families.
- Support and monitor patients with mild depression.
- Provide SSRI treatment for moderate to severe depression when appropriate.
- Help access evidence-based psychotherapy (such as CBT and IPT-A) when needed.
- Negotiate roles and responsibilities when referring to or consulting with mental health clinicians.
- Monitor for symptom improvement and medication side effects.
- Track outcomes of patients identified with depression even if referred to mental health.
Dr. Zuckerbrot and Dr. Cheung are lead authors of the guidelines and members of the GLAD-PC project team.