New guidelines issued for adolescent depression in primary care

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The American Academy of Pediatrics has updated clinical practice guidelines to assist primary care clinicians in the management of adolescent depression.
The American Academy of Pediatrics has updated clinical practice guidelines to assist primary care clinicians in the management of adolescent depression.

The American Academy of Pediatrics (AAP) has updated clinical practice guidelines to assist primary care clinicians in the management of adolescent depression, as published in Pediatrics.

One of the guidelines' major updates is the endorsement of universal adolescent depression screening for those aged 12 and older using a formal depression self-report tool. The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) had not been updated since 2008.

Part I of the guidelines addresses practice preparation, identification, assessment, and initial management of adolescent depression in primary care settings, whereas Part II addresses treatment, as well as the ongoing management of adolescent depression in the primary care setting.

“It has been over 10 years since the initial publication and AAP endorsement of GLAD-PC, yet many primary care pediatricians still are not practicing evidence-based management of adolescent depression,” stated Rachel A. Zuckerbrot, MD, FAAP, and Amy H. Cheung, MD, the lead authors of the guidelines and members of the GLAD-PC project team. “Some even say it is not in their scope of practice despite the AAP endorsement.”

Part I of the guidelines was developed by using a combination of evidence- and consensus-based methods in 2 phases as informed by current scientific evidence (published and unpublished) and draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience. Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in primary care, including the identification of at-risk youth, assessment and diagnosis, and initial management.

The recommendations in Part I for identification and surveillance are:

  • Recommendation 1: Adolescent patients aged 12 years and older should be screened annually for depression (MDD or depressive disorders) with a formal self-report screening tool either on paper or electronically (universal screening) (grade of evidence: 2; strength of recommendation: very strong).
  • Recommendation 2: Patients with depression risk factors (eg, a history of previous depressive episodes, a family history, other psychiatric disorders, substance use, trauma, psychosocial adversity, frequent somatic complaints, previous high-scoring screens without a depression diagnosis, etc) should be identified (grade of evidence: 2; strength of recommendation: very strong) and systematically monitored over time for the development of a depressive disorder by using a formal depression instrument or tool (targeted screening) (grade of evidence: 2; strength of recommendation: very strong).

The recommendations in Part I for assessment and/or diagnosis are:

  • Recommendation 1: PC clinicians should evaluate for depression in those who screen positive on the formal screening tool (whether it is used as part of universal or targeted screening), in those who present with any emotional problem as the chief complaint, and in those in whom depression is highly suspected despite a negative screen result. Clinicians should assess for depressive symptoms on the basis of the diagnostic criteria established in the DSM-5 or the International Classification of Diseases, 10th Revision (grade of evidence: 3; strength of recommendation: very strong) and should use standardized depression tools to aid in the assessment (if they are not already used as part of the screening process) (grade of evidence: 1; strength of recommendation: very strong).
  • Recommendation 2: Assessment for depression should include direct interviews with the patients and families and/or caregivers (grade of evidence: 2; strength of recommendation: very strong) and should include the assessment of functional impairment in different domains (grade of evidence: 1; strength of recommendation: very strong) and other existing psychiatric conditions (grade of evidence: 1; strength of recommendation: very strong). Clinicians should remember to interview an adolescent alone.

The recommendations in Part I for the initial management of depression are:

  • Recommendation 1: Clinicians should educate and counsel families and patients about depression and options for the management of depression (grade of evidence: 5; strength of recommendation: very strong).
    • Clinicians should also discuss the limits of confidentiality with the adolescent and family (grade of evidence: 5; strength of recommendation: very strong).
  • Recommendation 2: Primary care clinicians should develop a treatment plan with patients and families (grade of evidence: 5; strength of recommendation: very strong) and set specific treatment goals in key areas of functioning, including home, peer, and school settings (grade of evidence: 5; strength of recommendation: very strong).
  • Recommendation 3: All management should include the establishment of a safety plan, which includes restricting lethal means, engaging a concerned third party, and developing an emergency communication mechanism should the patient deteriorate, become actively suicidal or dangerous to others, or experience an acute crisis associated with psychosocial stressors, especially during the period of initial treatment, when safety concerns are the highest (grade of evidence: 3; strength of recommendation: very strong).

Part II of the guidelines focuses on treatment and ongoing management and has an expanded section on integrated behavioral health and collaborative care models.

  • Recommendation 1: Primary care clinicians should work with administration to organize their clinical settings to reflect best practices in integrated and/or collaborative care models (ie, facilitating contact with psychiatrists, case managers, embedded therapists) (grade of evidence: 4; strength of recommendation: very strong).
  • Recommendation 2: After initial diagnosis, in cases of mild depression, clinicians should consider a period of active support and monitoring before starting evidence-based treatment (grade of evidence: 3; strength of recommendation: very strong).
  • Recommendation 3: If a primary care clinician identifies an adolescent with moderate or severe depression or complicating factors and/ or conditions such as coexisting substance abuse or psychosis, consultation with a mental health specialist should be considered (grade of evidence: 5; strength of recommendation: strong).
    • Appropriate roles and responsibilities for ongoing co-management by the primary care clinician and mental health clinician(s) should be communicated and agreed on (grade of evidence: 5; strength of recommendation: strong).
    • The patient and family should be active team members and approve the roles of the PC and mental health clinicians (grade of evidence: 5; strength of recommendation: strong).
  • Recommendation 4: Primary care clinicians should recommend scientifically tested and proven treatments (ie, psychotherapies, such as CBT or IPT-A, and/or antidepressant treatment, such as SSRIs) whenever possible and appropriate to achieve the goals of the treatment plan (grade of evidence: 1; strength of recommendation: very strong).
  • Recommendation 5: Primary care clinicians should monitor for the emergence of adverse events during antidepressant treatment (SSRIs) (grade of evidence: 3; strength of recommendation: very strong).

References

  1. Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D. Guidelines for adolescent depression in primary care (GLAD-PC): part I. Practice preparation, identification, assessment, and initial management. Pediatrics. February 2018. DOI: 10.1542/peds.2017-4081
  2. Cheung A, Zuckerbrot RA, Jensen PS, Laraque D, Stein REK. Guidelines for adolescent depression in primary care (GLAD-PC): part II. Treatment and ongoing management. Pediatrics. February 2018. DOI: 10.1542/peds.2017-4082
  3. Zuckerbrot RA, Cheung A. Treating depression in youths: AAP endorses updated GLAD-PC guidelines [news release]. Pediatrics. February 26, 2017. Accessible at: http://www.aappublications.org/news/2018/02/26/depression022618?utm_source=TrendMD&utm_medium=TrendMD&utm_campaign=AAPNews_TrendMD_0 
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