#57: Depression – A SIGnificantEly CAPtivating Discussion from Diagnosis to Treatment

July 27, 2022 | By Sam Masur

Summary

This episode covers the essential tools for non-psychiatry pediatric providers to use in their everyday practices. We discuss the fundamentals of proper screening, diagnosis, initial treatment of patients with depression and, importantly, when to seek help. With Dr. Nadia Zaim, a pediatrics-trained child and adolescent psychiatrist as your guide, you will leave this episode feeling confident to care for patients with depression.

Credits

• Producer, Writer, Infographic: Audra Iness MD, PhD
• Executive Producer: Max Cruz MD
• Showrunner: Sam Masur MD
• Cover Art: Chris Chiu MD
• Hosts: Chris Chiu MD, Justin Berk MD
•  Editor: Justin Berk MD; Clair Morgan of nodderly.com
• Guest: Nadia Zaim, MD

Depression Pearls

1. Depression is a medical illness characterized by a defined cluster of signs and symptoms.
2. Depression has evidence-based treatments. Check out the GLAD-PC toolkit: http://www.gladpc.org
3. Utilize your state Child Psychiatry Access Program for telemedicine consultation support: https://www.nncpap.org

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Depression Notes

Screening and diagnosis

Screening

• USPSTF recommends initiating screening at age 12 
• Depression can present at a younger age, but is often characterized by more non-specific symptoms (e.g. behavioral problems, irritability)
• There is no formal guidance for the frequency of screening, but Dr. Zaim recommends annually or more frequently, if needed (see below). Pro-tip: have the patient fill it out in the waiting room for maximum efficiency!
• GLAD-PC guidelines recommend use of the PHQ9 questionnaire for screening 
• The PHQ9 is a screening tool, NOT diagnostic: can get positive signals in the setting of bereavement, stress, etc. so it is important to follow up with a clinical interview to gather more information

Diagnosis

• Dr. Zaim encourages asking all patients about suicidal ideation, even in school-age children, because rates of suicide are increasing in the setting of the COVID-19 pandemic
• Per Dr. Zaim, family meetings can help mitigate intra-familial conflicts and support the patient. Parents may need help as well to help take best care of the patient.
• Differentiating depression with co-morbid anxiety versus depression with anxious features: ask about the timeline- if anxious symptoms coincide with development of depressed mood, then likely depression with anxious features. Co-morbid anxiety is likely persistent throughout life regardless of depressive symptoms. 

Treatment

• The Treatment for Adolescents with Depression Study (TADS): Randomized controlled trial of Fluoxetine v. CBT (Cognitive Behavioral Therapy) v. Fluoxetine + CBT – the combination of Fluoxetine + CBT yielded an accelerated treatment response, but all arms of the study were efficacious. Dr. Zaim suggests shared decision-making based on the individual patient and clinical environment. 
• Dr. Zaim’s approach to prescribing SSRIs: start with fluoxetine because FDA approved for adolescents and has a long half-life to avoid discontinuation symptoms in the setting of poor adherence
• Escitalopram or sertraline are also reasonable options
• Main early side effects: headache, stomachache
• FDA black box warning: Patients experience increased energy prior to improvement in negative thoughts = increased risk of SI. Set routine check ins as a mitigation strategy.
• Increased SI but not actual suicide; post-mortem autopsies had no therapeutic levels of SSRI at the time of death
• Other side effects: activation (increase in energy and/or decreased need for sleep); mania (unmasking of bipolar disorder)
• Fluoxetine dosing: start at 10mg, titrate to 20-40mg (therapeutic range) weekly by increments of 10mg
• May need higher dose of SSRI to treat co-morbid anxiety with depression, but want to titrate slowly to avoid adverse effects given anxiety is a potential early side effect of SSRI initiation
• Monitoring treatment response: assess every 2 weeks for the first month, then every month for a few months, then every 3 months thereafter. Repeating the PHQ9 can be helpful, but is not fully validated as a tracking tool; interview the patient and the parents to get a sense of response 

Psychiatry Referral

• Refer to psychiatry if patient fails 2 SSRIs
• Will augment therapy with mood stabilizers, anti-psychotics, or transition to SNRI
• Electro-convulsive therapy (ECT) is available only in certain states

Suicide

Risk Stratification 

• Chronic factors: family and/or personal history of mood disorder, history of suicide completion in family member, trauma, adverse childhood experiences, minority groups
• Acute factors: current episode of depression, access to means (e.g. gun at home), acute grief, increased anxiety, decreased sleep, increased SI with a plan
• Mitigating/protective factors: supportive family, mitigating access to means (e.g. sharps, medications, firearms), hope for the future, positive social network, connection with good outpatient care
• Gun safety: remove from home, if possible. If not, lock gun and ammunition in separate biometric (fingerprint) safes

Inpatient Admission

• If high risk, patient should be sent to the Emergency Department and likely admitted to the hospital 
• Should have safety plan in place and support from family before going home
• Inpatient admission: timeline typically 5-7 days
• Goals of admission: Titrate medications quickly (because able to closely monitor for side effects), equip patient with coping skills (e.g. dialectical behavioral therapy), integrate patient into outpatient follow up care, and complete thorough safety plan with family

Goal

Listeners will explain the approach to screening, diagnosis, and treatment of depression along with risk stratification for suicide.  

Learning objectives

After listening to this episode listeners will…  

1. Describe the process for age-appropriate screening for depression. 
2. Be familiar with the diagnostic criteria for depression and practical application of these criteria for various developmental levels.
3. Feel comfortable initiating first line treatments for depression.
4. Understand when referrals to psychiatry specialists are appropriate.
5. Recognize risk factors for suicide and escalate care as necessary. 
6. List goals of inpatient psychiatry admission.

Disclosures

Dr. Zaim reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Iness AN, Zaim N, Cruz M, Masur S, Chiu C, Berk J. “#57: Depression – A SIGnificantEly CAPtivating Discussion from Diagnosis to Treatment”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ July 27, 2022.