In the Journals

Teen depression guidelines stress collaborative care, adequate treatment

Updated clinical guidelines issued by the AAP provide treatment and ongoing management of adolescent depression within a primary care setting and include the use of antidepressants and the formation of a collaborative care model.

“Because adolescents face barriers to receive specialty mental health services, only a small percentage of depressed adolescents are treated by mental health professionals,” Amy H. Cheung, MD, from the University of Toronto, and colleagues wrote. “As a result, primary care settings have become the de facto mental health clinics for this population, although most primary care clinicians feel inadequately trained, supported or reimbursed for the management of depression.”

The researchers noted that successful management of mental health requires care teams comprised of health care professionals from multiple disciplines who strive to recognize and follow up with target populations, provide collaborative care, create organized protocols for symptom management and support patient management of symptoms.

This model of treatment combines components to better care for patients and includes collaboration between mental health professionals, patients and families, as well as educational measures for primary care providers, patients and their families. Additionally, care plans that involve resources provided by other agencies or the community are established in this model, and enhanced communication between all providers is experienced.

When Cheung and colleagues assessed individual clinical trial results and evidence from systematic reviews, adolescent use of antidepressants continued to be supported for treatment of major depressive disorder. Response rates this type of drug ranged from 47% to 69%, with those receiving a placebo having a response rate ranging from 33% to 57%.

Depression
Researchers note that it is critical that training programs for primary care providers increase their focus on mental health issues.
Source:Shutterstock

The most impactful improvements in depressive symptoms, demonstrated in the Treatment of Adolescent Depression Study, included a combination of treatments which included fluoxetine and cognitive behavioral therapy (CBT) or fluoxetine alone. The researchers noted that when medications are used for the treatment of major depressive disorder, initial response rates were accelerated when medication was started first or with CBT.

Although significant improvements can be achieved with the use of antidepressants, adverse events are common in adolescents. Nausea, headaches, behavioral activation and other effects can occur in most adolescents; however, duloxetine, venlafaxine and paroxetine were reported to be the most unendurable. Cheung and colleagues wrote that the initiation of new or increasing suicidality is the most significant adverse event that can be experienced when taking antidepressants.

The researchers also consulted studies that examined the efficacy of CBT and interpersonal psychotherapy for adolescents (IPT-A). In one study that examined the effect of 12 weeks of CBT (15 sessions), post-treatment response rates (43.2%) were not significantly dissimilar from placebo (34.8%).

However, when computerized CBT was used in a different study, those who were assigned to the intervention had substantially larger reductions in Children’s Depression Rating Scale scores, as well as Reynolds Adolescent Depression Scale scores. Furthermore, those who received the intervention were more frequently experiencing remission of symptoms or a substantial reduction of symptoms than those on a waitlist for the intervention.

Additionally, an alternate therapy option — IPT-A — was found to reduce the severity of depression when administered in schools compared to usual treatment measures. These effects were most frequently observed regarding suicidal ideation and hopelessness.

Cheung and colleagues recommend the following for the treatment of adolescent depression in a primary care setting:

  • A collaborative effort should be made between primary care clinicians and administration to promote best practices regarding integrated and/or collaborative care models;
  • Active support and observation should be considered for adolescents with a diagnosis of mild depression before initiating evidence-based treatment;
  • In cases of moderate or severe depression, or depression with substance abuse, psychosis or other complicating factors, primary care clinicians should consider consultation with a mental health specialist, with specific communication about roles and responsibilities of health care professionals as well as patient and family involvement;
  • Evidence-based treatment methods, such as CBT, IPT-A and antidepressant use, should be used appropriately and whenever possible to accomplish goals set within the patient’s care plan; and
  • When beginning antidepressant treatment, primary care clinicians should observe the patient’s health status for adverse events.

    The researchers also suggest the following steps for the ongoing management of adolescent patients who have depressive symptoms of varying degrees:

  • Symptoms should be assessed along with functioning in home, school and peer settings for systemic and regular tracking of goals and outcomes concerning treatment;
  • If no improvement is observed after 6 to 8 weeks, a reassessment of the adolescent’s diagnosis and initial treatment should be made, and consultation of mental health resources should be considered;
  • Patients who experience only partial improvement after receiving a diagnosis and all treatments have been used within the primary care setting, including poor adherence, additional disorders and conflicts or abuse, consultation from a mental health resource should be considered;
  • Adolescents with depressive symptoms that have been referred to further mental health services should receive support from primary care clinicians to ensure appropriate management, with consideration given to the distribution of roles with mental health agencies and professionals; and
  • Communication should occur between primary care and mental health clinicians regarding roles and responsibilities for adequate co-management of care.

“It is critical that training programs for primary care providers increase their focus on mental health issues and that trainees in both primary care and specialty care areas be helped to hone their skills in working in collaborative care models,” Cheung and colleagues wrote. “For providers who are currently practicing, continuing education should strengthen skills in collaborative work and specifically, for primary care providers, increase skills and knowledge in the management of depression.” – by Katherine Bortz

Disclosures:  Cheung reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Updated clinical guidelines issued by the AAP provide treatment and ongoing management of adolescent depression within a primary care setting and include the use of antidepressants and the formation of a collaborative care model.

“Because adolescents face barriers to receive specialty mental health services, only a small percentage of depressed adolescents are treated by mental health professionals,” Amy H. Cheung, MD, from the University of Toronto, and colleagues wrote. “As a result, primary care settings have become the de facto mental health clinics for this population, although most primary care clinicians feel inadequately trained, supported or reimbursed for the management of depression.”

The researchers noted that successful management of mental health requires care teams comprised of health care professionals from multiple disciplines who strive to recognize and follow up with target populations, provide collaborative care, create organized protocols for symptom management and support patient management of symptoms.

This model of treatment combines components to better care for patients and includes collaboration between mental health professionals, patients and families, as well as educational measures for primary care providers, patients and their families. Additionally, care plans that involve resources provided by other agencies or the community are established in this model, and enhanced communication between all providers is experienced.

When Cheung and colleagues assessed individual clinical trial results and evidence from systematic reviews, adolescent use of antidepressants continued to be supported for treatment of major depressive disorder. Response rates this type of drug ranged from 47% to 69%, with those receiving a placebo having a response rate ranging from 33% to 57%.

Depression
Researchers note that it is critical that training programs for primary care providers increase their focus on mental health issues.
Source:Shutterstock

The most impactful improvements in depressive symptoms, demonstrated in the Treatment of Adolescent Depression Study, included a combination of treatments which included fluoxetine and cognitive behavioral therapy (CBT) or fluoxetine alone. The researchers noted that when medications are used for the treatment of major depressive disorder, initial response rates were accelerated when medication was started first or with CBT.

Although significant improvements can be achieved with the use of antidepressants, adverse events are common in adolescents. Nausea, headaches, behavioral activation and other effects can occur in most adolescents; however, duloxetine, venlafaxine and paroxetine were reported to be the most unendurable. Cheung and colleagues wrote that the initiation of new or increasing suicidality is the most significant adverse event that can be experienced when taking antidepressants.

The researchers also consulted studies that examined the efficacy of CBT and interpersonal psychotherapy for adolescents (IPT-A). In one study that examined the effect of 12 weeks of CBT (15 sessions), post-treatment response rates (43.2%) were not significantly dissimilar from placebo (34.8%).

However, when computerized CBT was used in a different study, those who were assigned to the intervention had substantially larger reductions in Children’s Depression Rating Scale scores, as well as Reynolds Adolescent Depression Scale scores. Furthermore, those who received the intervention were more frequently experiencing remission of symptoms or a substantial reduction of symptoms than those on a waitlist for the intervention.

Additionally, an alternate therapy option — IPT-A — was found to reduce the severity of depression when administered in schools compared to usual treatment measures. These effects were most frequently observed regarding suicidal ideation and hopelessness.

Cheung and colleagues recommend the following for the treatment of adolescent depression in a primary care setting:

  • A collaborative effort should be made between primary care clinicians and administration to promote best practices regarding integrated and/or collaborative care models;
  • Active support and observation should be considered for adolescents with a diagnosis of mild depression before initiating evidence-based treatment;
  • In cases of moderate or severe depression, or depression with substance abuse, psychosis or other complicating factors, primary care clinicians should consider consultation with a mental health specialist, with specific communication about roles and responsibilities of health care professionals as well as patient and family involvement;
  • Evidence-based treatment methods, such as CBT, IPT-A and antidepressant use, should be used appropriately and whenever possible to accomplish goals set within the patient’s care plan; and
  • When beginning antidepressant treatment, primary care clinicians should observe the patient’s health status for adverse events.

    The researchers also suggest the following steps for the ongoing management of adolescent patients who have depressive symptoms of varying degrees:

  • Symptoms should be assessed along with functioning in home, school and peer settings for systemic and regular tracking of goals and outcomes concerning treatment;
  • If no improvement is observed after 6 to 8 weeks, a reassessment of the adolescent’s diagnosis and initial treatment should be made, and consultation of mental health resources should be considered;
  • Patients who experience only partial improvement after receiving a diagnosis and all treatments have been used within the primary care setting, including poor adherence, additional disorders and conflicts or abuse, consultation from a mental health resource should be considered;
  • Adolescents with depressive symptoms that have been referred to further mental health services should receive support from primary care clinicians to ensure appropriate management, with consideration given to the distribution of roles with mental health agencies and professionals; and
  • Communication should occur between primary care and mental health clinicians regarding roles and responsibilities for adequate co-management of care.

“It is critical that training programs for primary care providers increase their focus on mental health issues and that trainees in both primary care and specialty care areas be helped to hone their skills in working in collaborative care models,” Cheung and colleagues wrote. “For providers who are currently practicing, continuing education should strengthen skills in collaborative work and specifically, for primary care providers, increase skills and knowledge in the management of depression.” – by Katherine Bortz

Disclosures:  Cheung reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.