An updated guideline issued by the AAP stresses the importance of proper screening and identification of adolescents with symptoms of depression in a primary care setting.
These suggestions include the use of universal screening for those 12 years of age and older and classifications for mild, moderate and severe depression.
“In primary care, as many as two in three youth with depression are not identified by their clinicians and fail to receive any kind of care,” Rachel A. Zuckerbrot, MD, from the division of child and adolescent psychiatry, department of psychiatry, Columbia University Medical Center, and New York State Psychiatric Institute, and colleagues wrote. “Even when diagnosed by primary care providers, only half of these patients are treated appropriately. Furthermore, rates of completion of specialty mental health referral for youth with a recognized emotional disorder from general medical settings are low.”
The guidelines are intended for identifying and assisting adolescents aged between 10 and 21 years, an age range in which individuals may be considered developmentally adolescent, and were developed for primary care clinicians. For those aged between 18 and 21 years, Zuckerbrot and colleagues note that the clinician can use either adolescent or adult guidelines based on the developmental status of the patient and the clinician’s knowledge and comfort level with the guidelines.
The researchers reiterate that diagnosing major depressive disorder is a process that should be guided by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The specific diagnosis includes episodes lasting a minimum of 2 weeks that impact affect, cognition and neurovegitative functions, as well as interepisode remissions. This diagnosis is separate from persistent depressive disorder, premenstrual dysphoric disorder, bipolar disorder and other related disorders listed in the DSM-5.
Updated guidelines issued by the AAP include classifications for mild, moderate and severe depression and call for universal screening of all children 12 years of age and older.
These updated guidelines also include information on determining whether depressive episodes should be classified as mild, moderate or severe. The DSM-5 suggests that symptom count, intensity and impairment level can be used to determine the severity of depressive disorders. Within the primary care setting, lower scores on standardized depression scales, shorter length of symptoms and minimal criteria and mild impairment in functioning may be more commonly encountered, and mild depression may be defined in the DSM-5 with five or six mild symptoms.
Severe depression may be classified based on multiple criteria. Zuckerbrot and colleagues recommend that a severe diagnosis may be considered if an adolescent experiences all depressive symptoms listed in the DSM-5 or if functioning has been severely limited because of symptoms.
Those who meet five or more criteria listed in the DSM-5 that have specific plans for suicide, clear intent or have recently attempted suicide; exhibit psychotic symptoms; have a first-degree relative with a bipolar disorder diagnosis; or experience extreme functioning limitations such as the inability to leave home should also be diagnosed and classified with severe major depressive disorder.
Zuckerbrot and colleagues recommend the following for the identification and surveillance of major depressive disorder and other depressive disorders:
- Annual depression screening should be conducted for patients 12 years of age through a paper or electronic self-report screening tool; and
- Those who have previous depressive episodes, family history of depression or related disorders, additional psychiatric disorders,substance use, trauma and other risk factors for depression should be recognized and observed for a period of time using a formal depression instrument or tool to determine if a depressive disorder has developed.
The following recommendations have been made for assessment and diagnosis of depression in adolescents:
- Those who screen positive for depression with formal screening tools, have a primary complaint of emotional concerns or are highly suspected of depression with a negative screening result should be evaluated by a primary care clinician for depression using diagnostic criteria from the DSM-5 or the International Classification of Diseases, 10th Edition, along with standardized depression tools; and
- Interviews with patients and parents and/or caregivers should include questions based on functional impairment and additional psychiatric conditions, with the adolescent interviewed alone.
Furthermore, the researchers suggest the following for initial management of depression in this age group:
- Teenagers and their families should be educated and advised regarding depression and the options available for management, with specific discussions related to the limits of confidentiality;
- Treatment plans should be developed with patients and families once appropriate training has been completed, with treatment goals for the improvement of functioning, which may include areas related to home, peer and school settings; and
- Safety plans — which include the limiting of lethal means, having a concerned third party involved and a plan for emergency communication — should be established in all discussions of management within the home and the community.
“Although not definitive and subject to modification on the basis of the ongoing accumulation of additional evidence, this part of the updated guidelines is intended to help address the lack of recommendations regarding practice preparation, screening, diagnosis and initial management of depression in adolescents aged 10 to 21 years in primary care settings in the United States and Canada,” the researchers wrote.
“As such, these guidelines are intended to assist primary care clinicians in family medicine, pediatrics, nursing and internal medicine, who may be the first — and sometimes only — clinicians to identify, manage and possibly treat adolescent depression,” they continued. – by Katherine Bortz
Disclosures: Zuckerbrot works for CAP-PC, child and adolescent psychiatry for primary care, now a regional provider for Project TEACH in New York State. She is also on the steering committee as well as faculty for the REACH Institute. Both institutions are described in the published statement on the guidelines. Zuckerbrot also received book royalties from Research Civic Institute. Please see the study for a full list of relevant financial disclosures.