Depression Management in Primary Care

According to the CDC, 1.9 million children aged 13-17 years old have been diagnosed with depression

Depression is one of the most common mental health conditions in childhood, especially now with the isolation brought on by COVID.  Teen suicide is the second most common cause of death and often associated with depression. Both depression and suicide have dramatically increased in this pandemic. Detecting depression is not always easy as it is less evident to parents than acting out behaviors. Using a screening tool, such as the Patient Health Questionnaire- 9 (PHQ-9) is better way to detect depression and more time efficient than asking; especially done online or on paper. The PHQ-9 has a recommended cut score of greater than 10, but 5-9 is considered mild depression symptoms. A clinical interview is always also required.

But what should the clinician do when a screen is positive? The Guidelines for Adolescent Depression in Primary Care (GLAD-PC), an expert consensus document, contains specific and practical guidance for all levels of depression. But for mild depression, GLAD-PC advises primary care providers begin “a period of active support and monitoring before starting evidence-based treatment”. After making an assessment of symptoms, severity and impact and ruling out significant suicide risk, we need to talk clearly and empathically with the teen (and parents with consent) about depression, its neurological etiology, ask about contributing stress and genetic factors, and describe the typical course with optimism. Substance use, including alcohol, must be addressed as both a possible cause and attempted coping strategy for depression as it adds to risk for suicide or car crashes, and can interact with medicines.

GLAD-PC provides a “Self-Care Success!” worksheet of categories for goal setting for active support. These goals include: Stay Physically Active; Spirituality and fun activities; Eat balanced meals; Spend time with people who can support you; Spend time relaxing; and Small Goals and Simple Steps (for a specified problem with relevant goals and steps).

If mild depression fails to improve over several months or worsens or the child has moderate or severe depression, GLAD-PC describes evidence-based treatments that should be initiated. In addition to the above activation activities, evidence-based treatment with Cognitive Behavior Therapy (CBT) or Interpersonal Therapy (IPT)(for children over 12) should be prescribed and the effectiveness monitored. This is also indicated if depression was treated in the past or the current symptoms are severe or include comorbid conditions.

The basic principle of CBT is that thoughts influence behaviors and feelings, and vice versa. Treatment targets patients’ thoughts and behaviors to improve their mood. Treatment aims to increase engagement in pleasurable activities (behavioral activation), recognizing and working to reduce negative thoughts (cognitive restructuring), and improving assertiveness and problem-solving skills to reduce feelings of helplessness. The principle of IPT for teens is that interpersonal problems may cause or exacerbate depression and that depression, in turn, may exacerbate interpersonal problems. Treatment for adolescents involves discussion of patients’ interpersonal problems to improve both mood and interpersonal functioning by identifying an interpersonal problem area, improving interpersonal problem-solving skills, and modifying communication patterns.

For more severe depression, patients who decline therapy, prefer medication, or for whom therapy is not accessible should be offered medication, with the first line being Selective Serotonin Reuptake Inhibitors (SSRIs). Medication treatment for depression in teens is safe and effective. Common but manageable side effects may include GI disturbances, changes in appetite, sleep disturbance, and sexual dysfunction. If the patient becomes agitated, silly, speaks too fast, seems over-energetic, or sleeps less in the first two weeks it may be that the medicine is activating and should be reduced or stopped. It is important to educate families that treatment should continue at least 6 months to 1 year after symptoms improve.  Medication should be stopped gradually under a doctor’s supervision, to avoid discontinuation symptoms such as recurrence of depression, drowsiness, nausea, lethargy, headache, and dizziness. Even if symptoms remit, primary care active support and monitoring should continue, as depression tends to recur.

CHADIS Online Tools Paired with In-person and Televisits Facilitate Screening, Diagnosis, and Monitoring – Integrated with MicroMD

Primary care providers are key to early detection and ongoing management of depression but may lack training for this role. Chadis, a clinical process support system software as a service integrated with MicroMD, delivers all the recommended tools for screening, diagnosis and monitoring of depression for online completion from home, especially helpful when care is conducted by televisits. Chadis under NIH funding has also created a new comprehensive module that integrates patient questionnaire results into a template following the GLAD-PC guidelines including individualized teleprompters for the clinical interview, patient education handouts and activation activities that are automatically delivered to the teen’s secure portal.  A referral link in Chadis facilitates referral, tracking and consents needed for coordinated care with mental health specialists. The effectiveness of this module is being studied in pediatric practices. For more information or to join this study contact bhoward@chadis.com.

Are you interested in learning more about Chadis and MicroMD? Visit us at micromd.com/marketplace/clinical/chadis/ or call us at 800.624.8832.