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Depression and Anxiety Disorders: Evaluation and Management in Primary Care

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  1. Depression and Anxiety Disorders: Evaluation and Management in Primary Care Robert Hilt, MD, FAAP Assistant Professor Psychiatry, U of Washington Medical Director, Partnership Access Line Seattle Children’s Hospital

  2. Disclosures In the past 12 months, I have had not had any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial service(s) discussed in this CME activity.

  3. Disclosures, continued I will discuss unapproved/investigative uses of medications in my presentation. Seattle Skyline photo by Craig Allen, 2007

  4. A Case • 13 year old boy • “Headache evaluation” • Band-like around his head, recurrent • Sometimes associated with nausea • No neurologic symptoms • Better with Tylenol • Happens on most days

  5. Case Continued • Ask how rest of things going in life: • Irritable • sleeping more • grades falling • spends a lot of time alone in his room • No longer talks to friends on phone • Start to wonder about depression

  6. Childhood Major Depression, the basics • Point Prevalence • ~ 2% children • ~ 6% adolescents • Like with anxiety, somatic complaints are the common presentation in kids • Headache, stomach ache, fatigue Lewis, 2002; Weiner 2004

  7. Major Depression--Diagnosis • Same DSM-IV criteria as adults • 2 weeks of depressed mood plus 4 of the following changes (5 if mood is just irritable): • Sleep • Interest • Guilt • Energy • Concentration • Appetite • Psychomotor • Suicidality

  8. Clinical judgment trumps all • Major Depression • Dysthymia • Mild, chronic depression • You may judge child has “Depression NOS” even if not all criteria are met • Enough basis to initiate treatment

  9. Don’t Need to Rush the Evaluation • Ask them to come back a second time • Hand them rating scales, check back later after you pop into next room • Psychiatrists frequently see people a second time before diagnosing

  10. Rating scales exist to help you • Broad Screening • PSC-17 • SDQ ( • Others like CBCL, BASC for a fee

  11. Internalizing Depression Anxiety Attention Externalizing ODD Conduct No fee for use PSC-17 By Gardner et all 1999, from PSC by Jellinek M et al 1988 Formatting by

  12. Depression Rating Scales • Narrow Screening/Diagnostic aide • PHQ-9 for adolescents • SMFQ for kids over age 6 • Others like CDI, CDRS-R available for a fee • Can measure response to treatments

  13. Relatively depression specific 60% sensitivity 85% specificity Tested for age 6 and up No fee for use SMFQ By Angold and Costello, 1987 Free download at mfq.html

  14. Using Rating Scale Scores • Only as good as the information input • “Positive review of systems” • Adolescent who denies everything • Imperfect sensitivity/specificity • A high screening score can at least stimulate a pertinent discussion • Track scores over time—like a vital sign Birmaher, Brent, Chiappetta, et al 1999

  15. Ask About Suicidality • Part of every depression evaluation • Start broad • “Ever wish that you weren’t around?” • “Ever thought about killing yourself?” • Get specific • “In the past month, have you thought about killing yourself?” • “Have you made any plans for how you would kill yourself? What would you do?”

  16. Why Ask? Because Suicidality in Young People is Common US High school students in past 12 months: 13.8% seriously considered suicide 10.9% made a suicide plan 6.3% attempted suicide 1.9% needed MD treatment for an attempt • Per 2009 YRBS by CDC

  17. Suicide completions are rare • ~2000-3000 youth suicides in the whole country, per year • 49% by firearm • 38% by strangulation (hanging, asphyxiation) • 7% by poisoning/overdose • 6% by all other causes • First attempt is often the fatal one • ~1/2 of suicide completers had made no prior attempts on their own life CDC’s MMWR June 11, 2004; AACAP practice parameter 2001

  18. What about “cutting”?(and other self-injury behaviors) (Image from Flikr Creative Commons)

  19. Self Harm in Teenagers • Is Common (~15% of all US teenagers) • Self harm is often planned out • >½ plan more than an hour in advance • It happens at home ¾ of the time • Doctors rarely know about it (<14%) • Friends/family do know about it (~75%) • Occurrence is rarely influenced by substance abuse N Madge, E Hewitt et al, 2008 From Klonsky ED and Muehlenkamp JJ 2007

  20. Understanding Self-Harm --always a sign of psychological distress --usually a coping mechanism --sometimes an adolescent social experiment --only occasionally a sign that the child is at risk for a serious suicide attempt From Klonsky ED and Muehlenkamp JJ 2007

  21. What I do with “Cutting” and self harm • See the adolescent alone • Find out how often this happens • Ask if other forms of self harm occur • Ask about the intention behind the behavior, such as: • “Tell me about the last time you cut.” • “When you decided to cut, what did you think would happen?” • “How does cutting help you?”

  22. The Cutting Interview, continued • After they tell you the benefits of cutting, ask how long that benefit lasts --typically hear, “a few minutes” or “an hour or so” • Ask if a substitute experience helped them in the same way, would they want to try it --Usually they just need a strong sensory “jolt”

  23. Replacement Strong Sensory Suggestions • Taste: “atomic fireball”, sour candy, strong licorice • Touch: hold ice cube, apply lotion, warm bath, rubber band wrist snap • Hear: loud music, play instrument • Smell: “aromatherapy,” incense • Sight: action/violent movie or game

  24. Get Them to a Therapist • If having enough psychological distress to be repeatedly self-harming, refer them to a counselor

  25. Back to Depression

  26. What Can You Do for Child Depression? • Schedule frequent follow up visits • Prescribe behavioral activation, exercise • Recommend increased peer interactions • Recommend support groups, if available • Encourage good sleep hygiene • Encourage reduced stressors, if possible • ~¾ of youth suicide attempts immediately triggered by an interpersonal conflict Vitello, et al J Clin Psych 2009

  27. What You Can Do (continued) • Remove access to guns, dangerous pills • Lowers impulsive suicide risks • Offer a crisis line number • 800-SUICIDE or 800-273-TALK if no local options • Moderate/severe cases refer sooner than later to counseling • Provide psychoeducation

  28. Provide an Information Handout (Example from (Example from “Glad-PC”)

  29. Management • Follow up appointment in 2-4 weeks to check if situation is getting worse • Staying engaged is a valuable intervention • Repeating a rating scale helps monitor • Mild cases not improving on their own become referral candidates for counseling

  30. MDD—Treatment • Psychotherapy: a safe first line intervention • Randomized controlled trials support: • CBT: Cognitive Behavior Therapy • IPT: Interpersonal Therapy • CBT • Cognitive distortions • i.e. “everything goes wrong for me” • Behavior that impacts our feelings • i.e., physical inactivity lowers mood • Usu. requires “homework” between sessions

  31. What if Can’t Access CBT? • Try what is available • If have good “treatment alliance”, chances are it will help • All therapy is less effective when: • Hopeless • Suicidal • Active family conflict/abuse • Weak alliance with therapist Brent et al, 1997 AACAP Practice Parameter 2007

  32. What If Child Depression Is Not Treated? • Depression affects normal development • Natural remission takes ~8 months • Depression tends to come back • Recurrence rate 70% after one episode of MDD Kaplan and Sadock Comprehensive Textbook of Psychiatry, 2009

  33. Depression Medications

  34. MDD—Medications in Kids • Positive Randomized Controlled Trials • (that had a positive result on their primary outcome variable) • 3 fluoxetine • 1 fluoxetine (continuation phase) • 1 sertraline* • 1 citalopram* • 1 escitalopram • CGI: a clinician rates their global impression of improvement compared to baseline (Guy M, 1976) • “much or very much improved” as primary outcome in psychiatric trials • Was primary outcome for all but the citalopram trial above * Not FDA approved for depression in kids

  35. % Response Rates in those Positive Adolescent Depression Trials Response rate (CGI ≤2) 3 fluoxetine 52-61% vs. placebo 33-37% 1 sertraline63% vs. placebo 53% 1 citalopram* 47% vs. placebo 45% 1 escitalopram64% vs. placebo 53% *Note the CGI was not the primary outcome variable. Wagner et al 2003, 2004; March et al, 2004; Emslie et al 1997, 2002, 2008

  36. All known negative RCTs per the primary outcome variable (published and unpublished) Response rate (CGI ≤2) • 1 escitalopram63% vs. 52% placebo • 2 mirtazapine54-60% vs. 41-57% placebo • 2 nefazodone63-65% vs. 44-46% placebo • 3 paroxetine49-69% vs. 46-57% placebo • 2 venlafaxine50-68% vs. 41-61% placebo • 1 citalopram(CGI response rate not reported) Only escitalopram above is FDA approved for child depression FDA brief, 2004; GSK website; K Wagner 2009 AACAP annual meeting presentation; MHRA UK website

  37. Understanding The Trials • High placebo response rates • Placebo group gets frequent care appointments with a skilled child psychiatrist • “placebo” is not equivalent to “no treatment” • Expect spontaneous remission when treating mild depression • Design bias in “pharma” sponsored trials

  38. TADS—Treatment of Adolescent Depression Study • 439 adolescents • 12 week treatment • Moderate to severe depression • ~30% with suicidality • More than half had comorbid psychiatric illness • Community and academic centers • Randomized to: • fluoxetine • fluoxetine plus CBT • CBT alone • placebo TADS, 2005

  39. TADS Medication Protocol • Starting dose fluoxetine 10mg • Week two, increased to 20mg if no side effects • Dose could be increased at weeks 4, 6, 9 and 12 if still significant symptoms • Mean final dose was ~30mg/day

  40. TADS Results • Suicidal “events” decreased with all active treatments • At 36 week follow up more common with fluox alone (14%) than Combination (8%), or CBT (6%)

  41. TADS response rates (CGI≤2) equalize over time (Fluoxetine improved their depression more quickly)

  42. But Aren’t SSRI’s Dangerous for Kids? • FDA Black Box in 2004, based on 24 studies • For all diagnoses suicidality RR 1.95 (95%CI=1.28-2.98) T Hammad, T Laughren, 2006

  43. SSRI suicidality differences Risk Ratio 95% confidence interval • Venlafaxine RR 8.8 (1.12-69.5) • Sertraline RR 2.2 (0.48-9.62) • Paroxetine RR 2.2 (0.71-6.52) • Mirtazepine RR 1.6 (0.06-38.37) • Fluoxetine RR 1.5 (0.74-3.16) • Citalopram RR 1.4 (0.53-3.50) T Hammad, T Laughren, J Racoosin 2006

  44. SSRI’s Reducing Actual Suicides • US population studies show lower youth suicides in areas with higher use of SSRI • 14% increase in U.S. youth suicides in 2004, the year SSRI usage started falling due to the black box warnings Olfson, M et al. Arch Gen Psych 2003 Gibbons R et al. Arch Gen Psych 2004 Gibbons RD, Brown CH, et al 2007

  45. How I Make Sense of SSRI Suicidality • Agitation/anxiety is a known SSRI side effect • Common side effect, happens early on • If make depressed or anxious person more anxious, logical to get some suicidal thoughts • SSRI induced suicidal thoughts CAN happen, but they usually don’t • Why I check in with patient1-2 weeks after starting medicine • Much more likely to see treatment benefits from SSRI than to see an increase in suicidal thoughts Bridge et al, JAMA 2007

  46. Where I see the role of SSRI in Child Depression • Start with talk therapy alone if depression is not severe • If not significantly better within 1-2 months, strongly consider medication trial • If a moderate to severe depression, consider starting SSRI at same time as talk therapy

  47. Medicating Major Depression • 1st line medication is Fluoxetine (Prozac®) • FDA approved for child depression • Most evidence to support its use • 4 positive and no negative RCTs • Low suicidality signal in controlled studies • Long half life means no withdrawal symptoms from missed doses • Covered by all plans, and available generic

  48. Medicating Major Depression • Second line child medications • Sertraline (Zoloft®)* • 1 positive, no negative RCT • Citalopram (Celexa®)* • 1 positive, 1 negative RCT • Escitalopram (Lexapro®) • 1 positive, 1 negative RCT • FDA approved for child depression *Not FDA approved for depression treatment in children

  49. Suggested SSRI Dosages: Depression --If a pre-adolescent, would decrease all dosages by ~½ to 1/3rd *Not FDA approved for depression

  50. Medicating Major Depression • Change just one medicine at a time • Usually wait 4-6 weeks before increases • More severe = more rapid titration • Use a full dose range • Check in with patient 1-2 weeks after starting • Ask if new suicidality • Ask if new agitation, irritability