PCPs' Role in Screening and Treating Adolescents for Depression?
According to the National Comorbidity Survey-Adolescent Supplement (NCS-A), about 11 percent of adolescents have a depressive disorder by age 18, with the risk slightly higher in girls, and increasing as the child gets older. Most adolescents can be treated effectively with psychotherapy, antidepressant medication or a combination of the two, especially if the depression is caught early.
So why aren’t more pediatricians screening them for depression?
”There continues to be a range of concerns that prevent pediatricians from feeling comfortable screening, making a mental health-related diagnosis, and if needed, initiating treatment,” says Giuseppe Raviola, MD, MPH, director of the Psychiatry Quality Program at Boston Children’s Hospital. “For one, pediatricians don’t have a lot of time to see patients, meet with family members to obtain collateral information and provide education. Depression can involve various co-morbidities, and mental health is generally not an area in which pediatricians feel adequately trained.”
Another issue is a severe national shortage of child psychiatrists and other specialists, making it difficult for patients to access treatment.
Adding to pediatricians’ discomfort is concern about the safety of psychotropic medications such as selective serotonin reuptake inhibitor (SSRI) antidepressants—the drug class of choice for depression—stemming from a widely publicized 2003 FDA “black box” warning about a potential increase in suicides linked to the drugs.
Last month, a large study in the BMJ sounded a counter-warning, documenting a steep drop in antidepressant use among teens and young adults during the year after the 2003 warning. The drop was accompanied by an alarming 33.7 percent increase in suicide attempts via drug overdose alone. (Completed suicides are rare and showed no increase.)
So where does that leave the PCP?
First, treatment of teen depression is critical. It’s important to note that the studies cited by the FDA regarding SSRIs showed only an increase in the risk of suicidal thoughts, not in attempted or completed suicide. A 2007 meta-analysis of placebo-controlled studies, published by JAMA, concluded that the benefits of SSRIs appear much greater than risks of suicidal ideation or suicide attempt across all indications for their use. The analysis also found that antidepressants are efficacious for major depressive disorder in patients 18 and younger, though their benefit was stronger in patients with obsessive-compulsive disorder and non-OCD anxiety disorders.
Second, through ongoing training, PCPs can increase their comfort level in prescribing SSRIs and monitoring patients, Raviola says. While co-morbidities such as substance abuse or severe presentations of illness may warrant referral, courses such as those offered by the Resources for Advancing Children’s Health (REACH) Institute can strengthen pediatricians’ capacity to address a range of mental disorders in their practices.
The United States Preventive Services Task Force (USPSTF) recommends routine screening for depression in 12- to 18-year-olds in the primary care setting when appropriate mental health services, including confirmation of diagnosis, psychotherapy and follow-up, are available. A recent review found that a simple 20-item paper test called the CES-DC is a reliable, quick way of determining the need to refer a teen for mental health services. A shorter 10-item screen (CES-S) can also be used.
“There are a range of screening tools available,” Raviola says. “However, the choice of tool is less important than actually taking the time to ask each patient a few questions. Even a two-item screening questionnaire such as the PHQ-2 can be helpful in the primary care setting.” The PHQ-2 questions assess how often the individual has 1) felt down, depressed or hopeless or 2) felt little interest or pleasure in usual activities over the past two weeks.
Raviola also recommends that PCPs consider depression within the context of a broader range of potential psychosocial problems. An open-ended approach leading to the PHQ-2 questions, followed by the “11 Mental Health Action Signs,” provides a useful framework for having conversations with adolescents and their parents about mental health. PCPs might begin by saying, “Now I’d like to ask you about some other issues that I ask all parents and kids about.”
Boston Children’s Hospital’s Department of Psychiatry and Pediatric Physician’s Organization are offering training for PCPs at primary care sites on how to incorporate screening for depression—as well as attention, behavior, substance use and anxiety problems—into well-child visits. This effort is part of a larger program of integrating behavioral health specialists in primary care practices to provide expert support for PCPs and give families greater access to diagnostic and treatment services. This program will also help PCPs detect problems and intervene earlier, leading to better clinical outcomes and potential cost savings.