Depression in Adolescents – Practice Preparation, Identification, Assessment and Initial Management
Featured Reading 4: Depression in Adolescents – Practice Preparation, Identification, Assessment and Initial Management
Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics. 2018 Mar;141(3). doi: 10.1542/peds.2017-4081. PubMed PMID: 29483200.
PRACTICE PREPARATION AND IDENTIFICATION
The PCP and medical home team should seek on-going training (CME) in depression and establish relevant referral patterns with mental health resources in the community. Screen all adolescents ≥ 12 years annually for depression with a formal self-reporting screening tool (such as the PHQ-9). Identify and monitor patients with depression risk factors such as history of previous depressive episodes, family history of depression, substance use, psychosocial adversity, frequent somatic complaints, previous high-scoring depression screens without a depression diagnosis, and other psychiatric disorders.
ASSESSMENT AND DIAGNOSIS
Use the standardized depression tools and the diagnostic criteria from the DSM-5 to make a diagnosis of depression. The adolescent should be interviewed alone as well as with their families or caregivers and should include an assessment of functional impairment and existing psychiatric conditions.
MANAGEMENT OF DEPRESSION
First, discuss the limits of confidentiality with the adolescent and their family and educate about depression and options for management. Set specific treatment goals with the patient and family about the home, peer, and school settings. Establish a safety plan by restricting lethal means, engaging a 3rd party as a support network, and developing an emergency communication plan if the patient should deteriorate and be a danger to themselves or others. For mild depression, consider active support and monitoring before starting evidence-based treatment. For moderate to severe depression, comanagement by the PCP and a mental health provider is needed. Use evidence-based treatments such as psychotherapies (CBT or IPT-A) +/- SSRIs and closely monitor for any adverse events during antidepressant treatment (SSRIs). Diagnosis and initial treatment should be reassessment after 6-8 weeks if no improvement is noted. Continue to regularly track the depressive symptoms and functioning in the home, school, and peer settings. Continue to work closely with the mental health providers and discuss appropriate roles and responsibilities regarding comanagement of care and follow-up.