Dr. David Breland, an adolescent medicine specialist who conducts research on depression, comments on the recommendation to screen for depression in Bright Futures 2014 Recommendations for Preventive Pediatric Health Care and addresses questions about treatment.
Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Children’s medical staff and author of the Seattle Mama Doc blog, for submitting these questions.
Q. The new American Academy of Pediatrics (AAP)/Bright Futures guidelines recommend annual screening for depression in all children starting at age 11. How best should we do that – PHQ-9 or another tool?
In Adolescent Medicine at Seattle Children’s, we use the PHQ-9, which is available for free online and is useful to screen and assess severity. Given the time constraints of primary care visits, you could use the PHQ-2, which includes the first two items of the PHQ-9 about depressed mood and anhedonia. While these screening tools were originally used in adults, both were validated for use in adolescents ages 13 to 17 by my colleague, Dr. Laura Richardson.1,2
For children ages 11 and 12, you could use the Children’s Depression Inventory, which is validated for patients ages 7 to 17.
Q. While mental health referrals are the first treatment of choice, it can be difficult to find providers for children and teens with Department of Social and Health Services (DSHS) Medicaid insurance. Do you have any tips?
You can call the Partnership Access Line (PAL) for physicians at 866-599-PALS (7257) to consult with a Seattle Children’s mental health specialist immediately by phone or to access a rapid, in-person or telemedicine consultation for patients with DSHS Medicaid insurance. Locations include Seattle, Spokane, Olympia, Longview, Wenatchee and Richland.
Children’s Crisis Outreach Response System (CCORS) has a team of mental health providers who are on call. In a crisis, they can come to the home to do an assessment and follow up until the child can be seen in the mental health system.
Q. Many parents think depression is a problem for adults only. What statistics are most powerful to help families understand that children can also have depression? How potent is family history when it comes to children with depression?
Depression can occur in up to 14% of adolescents ages 13 to 17.3 It can lead to risky behaviors, including substance abuse and suicide. Children and adolescents with depression can go on to become adult patients with depression, so early intervention is important.
Biomedical and psychosocial risk factors include family history of depression, female sex, childhood abuse/neglect, stressful life events and chronic illness. All of these factors can increase the risk in a susceptible individual. Therefore, it is important to consider family history in assessing children and adolescents.4-6
We recently found that adolescents whose parents had a history of depression or who identified depression symptoms in their child were more likely to obtain care than other adolescents.7 It was concerning to find that adolescents with higher severity of symptoms were not more likely to obtain care. Over 50% of adolescents who were depressed in our study were getting care, but about 40% of depressed adolescents were not getting services for various reasons.
Our findings highlight the importance of parents’ role in seeking care and the need to screen all children. While further research is needed about interventions, educating parents about depression and addressing any biases about the diagnosis could help improve access to mental health services.
Q. In my experience, it can be challenging to get children and teens to comply with seeking mental health counseling for dysthymia or depression. Sometimes, even children or teens with severe depression will want medication over counseling. What new research exists to help us understand patterns? Are there any opportunities here?
I don’t think that, as a rule, adolescents prefer medications to counseling. There have been two published studies of collaborative care treatment interventions in primary care settings that offered adolescents the choice of treatment (antidepressant medication or psychotherapy). In one study, significantly more adolescents selected psychotherapy than medications; in the second, the sample was evenly split between the two.8,9
However, adolescents have definite opinions about the types of treatment they prefer and what would be acceptable. I also find that they are much more willing to engage in treatment when we honor their choices and preferences. When we listen to their preferences from the start, they may be willing to try something later that they were unwilling to try initially.
Cognitive behavioral therapy (CBT) is a well-established modality for patients with depression of varying levels of severity. Patients with mild depression can be treated with CBT alone. For moderate depression, patients can be treated with CBT or medication and CBT. For severe depression, the combined use of both modalities is recommended.
There is increasing evidence that interpersonal therapy (IPT) is effective in adolescents as well.10 For a comprehensive review about treating adolescent depression in primary care, see Cheung et al.11
If a patient doesn’t want to do therapy, sometimes, I prescribe the medication and then have them come back for a second visit. We discuss the symptoms and what the medication does and doesn’t do. I explain that the medication doesn’t help them develop coping mechanisms or tools to get through certain issues.
We often get referrals to Adolescent Medicine when a primary care provider would like another provider to talk to the patient and family. Sometimes, hearing the same message from different people can help them make a decision.
- Richardson LP, McCauley E, Grossman DC, McCarty CA, Richards J, Russo JE, et al. Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics. 2010;126(6):1117–1123.
- Richardson LP, Rockhill C, Russo JE, Grossman DC, Richards J, McCarty C, et al. Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics. 2010;125(5):e1097–1103.
- Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 2010;49(10):980–9.
- Bhatia SK, Bhatia SC. Childhood and adolescent depression. Am Fam Physician. 2007;75(1):73–80.
- Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, et al. Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry. 1996;53(4):339–348.
- Warner V, Weissman MM, Mufson L, Wickramaratne PJ. Grandparents, parents, and grandchildren at high risk for depression: a three-generation study. J Am Acad Child Adolesc Psychiatry. 1999;38(3):289–296.
- Breland DJ, McCarty CA, Zhou C, McCauley E, Rockhill C, Katon W, Richardson LP. Determinants of mental health service use among depressed adolescents. Gen Hosp Psychiatry. 2013. In press.
- Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial. JAMA. 2005;293(3):311–9.
- Richardson LP, McCauley E, Katon W. Collaborative care for adolescent depression: a pilot study. Gen Hosp Psychiatry. 2009;31(1):36–45.
- Mufson L, Weissman MM, Moreau D, Garfinkel R. Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 1999;56 :573– 579
- Cheung AH, Kozloff N, Sacks D. Curr Psychiatry Rep. 2013 Aug;15(8):381. doi: 10.1007/s11920-013-0381-4.