PCPs 'well positioned' for assessing, managing depression in adolescents

Key takeaways:

• A review of assessing and treating depression in adolescents described the best approaches to diagnosis and treatment.
• It was based on the latest evidence and international clinical practice guidelines.

Depression is often undiagnosed and untreated in adolescents; however, primary care physicians can help close these gaps in care, according to a review published in the Canadian Medical Association Journal.

More than 40% of people with depression face its onset before they reach adulthood, but clinicians consistently report a lack of confidence in their ability to treat depression in adolescents, Daphne Korczak, MD, MSc, a psychiatrist with the Hospital for Sick Children and the University of Toronto, and colleagues wrote.

So, they drew on recommendations from the latest evidence and clinical practice guidelines in Canada, the United States, Australia, the United Kingdom and New Zealand to review the diagnosis and management of depression in adolescents.

The review highlights that depression is an increasingly common yet treatable condition for adolescents and that PCPs can help patients to regain their health and function but also notes that there is a need for future research that should address important clinical questions in the detection and treatment of adolescent depression.

Korczac told Healio that the review “is intended to provide an overview of the etiology, presentation, assessment and treatment of depression for adolescents.”

“The key points to note are that depression is common, impairing and treatable, so that it is important to consider the diagnosis of depression for adolescents presenting with the symptoms discussed in the article,” Korczac said.

Screening

The United States Preventive Services Task Force recommends screening for major depressive disorder in adolescents aged 12 to 18 years.

Consistent with the recommendation, Korczac and colleagues suggest using the Patient Health Questionnaire-9 (PHQ-9), the PHQ modified for adolescents or the Center for Epidemiologic Studies Depression Scale for Children. All these options are in the public domain, they wrote.

They additionally noted that the PHQ-2 — which does not include questions related to suicidality — could be appropriate for an initial remote screen, alongside a subsequent in-clinic PHQ-9 if the first screen is positive.

The same tools, they wrote, could also be used for monitoring treatment response. But a physician needs a more thorough assessment of the patient for diagnosis.

Diagnosis

The criteria for a major depressive disorder diagnosis is at least 2 weeks of “a persistent change in mood that is either depressed or irritable, or persistent loss of interest or anhedonia,” that is also accompanied by at least three other symptoms of a major depressive episode present most days such as fatigue or loss of energy, insomnia or hypersomnia, weight loss or changes in appetite, recurrent thoughts of death or suicidal ideation, excessive or inappropriate guilt or feelings of worthlessness and more, according to the authors.

Notably, the symptoms must be a change from previous functioning and not attributable to medications, substances or other disorders, they wrote.

“Primary care providers, by virtue of their long-term knowledge of the patient and the family, are well positioned to assess adolescents for the presence of depression, rule out alternative potential etiologies for the patient’s presentation, and initiate first-line treatments when appropriate,” Korczac said.

Management

Managing depression in adolescents, Korczac and colleagues wrote, requires a multifaceted approach, including:

• risk assessment;
• lifestyle management, including strategies to improve sleep, dietary patterns and physical activity;
• psychoeducation;
• psychotherapeutic treatment — likely cognitive behavioral therapy, which is the psychotherapy with the greatest evidence for efficacy in the treatment of adolescent depression;
• pharmacologic treatment like antidepressants, which are recommended when psychological therapy is not effective or for young people with more severe clinical presentations; and
• interventions to address contributing factors.

“The review highlights the multimodal approach to the treatment of adolescent depression,” Korczac said. “This begins with risk assessment and psychoeducation and includes provision of evidence-based information about the potential benefits of improved health behaviors, psychotherapy, and medication, as well as addressing comorbidities and underlying stressors that may be contributing to the adolescent’s symptoms.”