I HAVE THIS PATIENT Managing Mood Disorders

“I HAVE THIS PATIENT……. ” Managing Mood Disorders in Primary Care Amy Heneghan, M. D. Pediatrics Palo Alto Medical Foundation Manpreet Singh, M. D. , M. S. Child & Adolescent Psychiatry Lucille Packard Children’s Hospital

Educational Objectives • Inspire you to embrace the role of primary care in screening and managing mood disorders – How to identify mood disorders in primary care – What constitutes management of mood disorders in primary care – When to refer to and collaborate with mental health colleagues • Increase your knowledge about treatment of mood disorders – Pharmacologic – Behavioral • Convince you to design your own practice to provide team based collaborative care – What are the principles of collaborative care

Mental Health Screening & Depression Management: Integral to Pediatric Primary Care Why: • Mental health issues are common in children and teens and can portend complex medical and mental disorders in adulthood Why primary care: • Primary care is usually the first and often the only contact that patients have with health care professionals. • Primary care interventions can be sufficient, without need for referral to mental health specialists. Who says so:

Epidemiology of Childhood Depression • ≈5% of children and adolescents in general population suffer from depression at any given time (2% children, 4 -8% adolescents) • Male: Female ratio 1: 1 during childhood, 1: 2 in adolescents • 1. 7% of children suffer from dysthymia (1. 6 -8% in adolescents) • Depressive disorders are appearing at a younger age of onset

CASE OF MY PATIENT (M. P. ) • 11 year old male presents for his annual check up – Doing well in school – Getting along at home with parents and siblings – Likes video games – Physical exam normal KEEP UP THE GOOD WORK! SEE YOU NEXT YEAR!

CASE OF MY PATIENT (M. P. ) • M. P back for his annual 12 year check up – Doing well in school – Fighting more with parents and siblings – Wants to play video games all the time – Physical exam normal; in early puberty COUNSELED ABOUT VIDEO GAMES, PEER RELATIONSHIPS, FAMILY RELATIONSHIPS, PUBERTY SCREEN FOR MOOD?

Readily Accessible Screening Tools General HEADDSS Depression: PHQ 9 PHQ 2 9 PHQ 9 for Teens 9 questions about depression & its severity 2 question screen, then 9 if screen is positive PHQ 9 + 2 ? ’s about suicidality Depression, ADD, Anxiety, Conduct Pediatric Symptom Checklist For Youth and Parent 37 questions about mood, behavior, attention issues 2 questions about suicidal thoughts, plans Drugs and Alcohol: CRAFFT 3 initial questions, then 6 more

PHQ 9 Modified for Teens Depression Severity Rating <5 None 5– 9 10 – 14 Mild Moderate 15 – 19 Mod. Severe 20 + Severe Impact on Function Not difficult Somewhat Difficult Very difficult Extremely Difficult

CASE OF MY PATIENT (M. P. ) – PHQ 9 for teens • Scored 6: – felt irritable, low energy, and like he was letting his family down. No functional impairment Depressed? Manic? Anxious?

Major Depressive Disorder Diagnosis DSM IV > 5 of 9 sx (must include mood issue) + impaired function • Mood: irritable or depressed plus • • Sleep: increased or insomnia Interest: markedly decreased in activities Guilt: feeling worthless, inappropriate guilt Energy: fatigue or loss of energy Concentration: hard to think/concentrate Appetite: significant wt loss / gain (~ 5% change) Psychomotor activity: physically slowed or agitated Suicide: thoughts, attempts, death thoughts

Grading Depression Severity Based on Sx and Function (DSM IV) Mild: 5 -6 sx of mild severity (including mood) + function mildly impaired or normal but w/ substantial and unusual effort Moderate in between mild and severe Severe: most sx present and severe + Function is disabled, clearly observable Or Psychotic features are present

Screen for Other Mood symptoms and Comorbidities • Physical illness: targeted review of systems, labs • Substance / alcohol use, 20 – 30% – usually follows depression onset by ~ 5 years • Other mood and psychiatric disorders: – Dysthymia, Bipolar Disorder, Anxiety, ADD, PDD, ODD or Conduct Disorders, Psychotic disorders (hallucinations, paranoia) • Abuse: physical / emotional / sexual

How mania present in kids Warning Signs Risk-taking behaviors with false beliefs of achievement Getting only a few hours of sleep but not feeling sleepy during the day (Children need 8 -10 hours of sleep; Adolescents 10 -12 hours) Sneaking out of the house, running away, sexual activity, using drugs “I hear voices telling me to hurt myself” “Energizer bunny” “My brain is going 100 miles/hour”; Jumping from topic to topic Grades getting worse from incomplete or unattempted school work Visits to the principal’s office for behavior problems. Talking too much, being loud, hard to interrupt or understand

Initial Management of M. P. • Form an alliance w/ the teen and affirm hope • Educate, counsel pt and family about depression, management options, limits of confidentiality • Establish a safety plan: restrict access to lethal means, engage 3 rd party to monitor for deterioration/risk, develop emergency communication plan to use if needed • Develop a specific tx plan and goals regarding function in home, school and peer relationships

Initial Management of M. P. (cont. ) Share resources for support: phone #s, websites, handouts Refer pt and family to mental health providers Arrange follow up visit within one week Have family sign release of information form to allow communication w/ school staff, outside providers. • Obtain information from and communicate w/ school staff, health care providers. Keep them informed about your tx plans and concerns. • • AAP http: //www. aap. org/stress/teen 1 -a. cfm Book: Ginsburg K, Building Resilience in Children and Teens: Giving Your Child Roots and Wings

Initial Treatment of Mild, Uncomplicated Depression • Active support through PCP • See pt weekly or biweekly x 6 – 8 wks: – Non directive support (support is equally effective as formal psychotherapy for mild depression) – Monitor depressive symptoms and function (school, home, peer) • If sx persist > 6 – 8 wks, offer psychotherapy and / or antidepressants • Refer patient and family to mental health care providers when appropriate

Psychological and Social Treatments • Stress management & regular sleep • Lifestyle: Exercise, weight control, avoid caffeine and alcohol • Resources and Support: AACAP, APA – – Youth Bipolar Foundation of Northern Calif (YBFNC)ybfnc. cfsites. org Child & Adolescent Bipolar Foundation (CABF) www. bpkids. org Depression & Bipolar Support Alliance (DBSA) www. dbsalliance. org American Foundation for Suicide Prevention (AFSP) www. afsp. org • School Intervention • Psychotherapy – Multifamily Psychoeducational Group therapy – Family Focused Therapy • Mood charting www. manicdepressive. org • Complementary and alternative medicine: Mental Health Naturally, by Kathi Kemper

Promoting Resiliency through Active Support Teen’s definition: Resilience means “bouncing back from problems and stuff with more power and more smarts. " Nurturing resiliency: • Demonstrate to pt that s/he has strengths (name them, show pt how s/he is using them, suggest how pt can use them in the future) • Be patient, keep communicating these to pt over serial visits Adapted from Nan Henderson, The Resiliency Training Program

CASE OF MY PATIENT (M. P. ) • Spoke to mother at 2 weeks, M. P better • 8 weeks later, mother calls: – Does not want to wake up in the morning for school – Note from teacher about missed assignment – Outbursts of anger at home and at soccer – Some nights does not sleep at all • PHQ 9 modified score 15 (moderate-severe) – very difficult to function – Not suicidal DEPRESSED? MANIC? ANXIOUS? REFERRAL?

Medication and Talk Therapy: Sequential or in Combination? TADS (Treatment for Adolescents with Depression Study): 439 teens 13 - 17 y/o with moderate to severe depression 1. Cognitive Beh Tx (CBT) + Fluoxetine 2. CBT alone 3. Fluoxetine alone – Higher first response rate CBT+ Fluoxetine combined - Improved @ 12 wks: 71% Combo (v. 61% SSRI v. 44% Talk; @ 36 wks: similar outcomes for all groups – Remission: faster for combo tx: by 36 wks: 55% for fluoxetine, 60% combo, 64% CBT – Anti depressants can take 1 – 3 months to work – Once stable continue med for 6 - 9 mo Treatment for Adolescents w/ Depression Study, Am J Psychiatry. 2009 ; 166(10): 1141 -1149. https: //trialweb. dcri. duke. edu/tads/manuals. html

Talk Therapy: What Works? Cognitive Behavioral Therapy (CBT) is effective and less costly than other talk tx, eg Interpersonal Therapy CBT Principles: thoughts cause feelings & behaviors, not external things (people, situations, events). Focus: Change the way you think and react in order to feel & act better even if externalities don’t change. Approaches: attend to thoughts and behaviors, practice to change them (in contrast to Interpersonal Therapy, which focuses primarily on improving relationships) Recommended by WHO Adopted by National Health Service, UK

Other Treatments to Initiate for Moderate Depression without complicating features Consider starting antidepressant after discussion w/ psychiatrist and recommend psychotherapy Or Refer to Psychiatrist If teen / family decline psychotherapy or psychiatrist: • Active support through PCP • See pt weekly or every other week x 6 – 8 wks: – Non directive support – Monitor depressive sx and function (school, home, peer)

When to Refer to Psychiatrist Anyone who wants such a referral Moderate Depression w/ Complicating Factors (eg substance abuse, ADHD, other psych illnesses) Severe Depression Suicidal patient

If Improved after 6 – 8 wks • Next 6 months: Continue meds after sx resolution; track adherence and side effects • After full remission: monitor monthly for 6 months • Up to 24 months: regular follow up in primary care

If not fully improved after 6 – 8 wks If Partially Improved If Not Improved • If no med, consider adding • Reassess dx and if confirmed, • If on med, consider increase dose • If no psychotherapy, start • Consult with or refer to psychiatrist • Review safety plan • Provide further education Do all actions noted on left

Before Starting Antidepressant Medication in Teens • Establish safety plan • Establish schedule for close follow up and communication • Review short & longer term side effects of meds and warning signs requiring immediate attention (including mania, suicidal ideation)

SSRI Antidepressant Prescription for Teens by PCPs Who says so? AAP, AACAP, PC-Glad - II Why? Many teens and / or parents are reluctant to seek help from mental health providers. Widespread problems with limited or delayed access to psychiatrists for teens Which pts? * uncomplicated mild depression that persists * moderate depression How? Guidelines are clear about how to start meds, follow pts and when to seek specialty referral

Medication for Teen Depression: SSRIs Doses, Efficacy and FDA Approval

Medication for Teen Depression: SSRI Side Effects

Required Followup Schedule for Teens on SSRIs for depression First f/u should be a face to face meeting w/ MD 1 wk after starting medication If pt is doing well, follow up schedule: • For 1 st month: Every week w/ MD or therapist • During 2 nd month: Every other week • After second month: Monthly thereafter If dose is changed, see pt in 2 wks See pt sooner for any concerns

CASE OF MY PATIENT (M. P. ) • Started on Prozac 10 mg daily • Seen biweekly; not improved and dose increased to 20 mg daily • Seen biweekly, not improved and dose increased to 20 mg daily • Symptoms improved markedly by week 12 • Returns with complaints of agitation/irritability • Next 6 months: Continue meds; track adherence and side effects abdominal pain • After full remission: monitor monthly for 6 -12 months suicidal thoughts weight gain

Standard of Care Assessing Suicide Risk Ask about both ideation and attempts Ideation* 1. Have you wished you were dead or you could go to sleep & not wake up? 2. Have you actually had any thoughts of killing yourself? 1. Have you made a suicide attempt? Tried to kill yourself? Attempts* 2. Done anything to harm yourself? 3. Anything dangerous where you could have died? *Adapted from the Columbia Suicide Severity Rating Scale, Posner et al 2009

“Black Box” Warning about Antidepressant use in Children and Teens In 2004, FDA reviewed 23 clinical trials (~ 4, 400 children & adolescents) rx’ed any of nine antidepressants for MDD, anxiety, or OCD Outcomes: • No completed suicides • Pts rx’ed anti depressants reported more suicidality (thoughts & attempts) vs. pts on placebo (4 vs. 2 out of 100). • Suicidality was not induced in pts without suicidality, not increased in pts who already had suicidality All studies showed reduced suicidality over tx course More SSRI rx’s associated w/ lower suicide rates

Collaborative Care: By Many Other Names…. Chronic Care Model Pt Centered Medical Home Pt centered, comprehensive, coordinate, superb access, and systems approach to quality and safety Who says? > 30 RCTs confirm this, eg IMPACT model* Who is using it: Mayo Clinic, Intermountain Health, Minnesota, U Washington, many public health clinics *Gilbody S et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006; 166(21): 2314 -2321

Collaborative Care for Depression is Best: It Takes a Team PCPs and mental health providers working together: Co location in same clinic Consults by phone, e - consults Sharing notes efficiently thru EHR or fax/mail Maximize EHR tools: track visits, PHQ scores, reminders, communicate w/ pts and team Observation for medication complication or side effects: weight gain, thyroid dysfunction, kidney and liver dysfunction Care Managers: MA, RN, or therapist educate, support pt self management recommend stepped care, adjusted for severity and response to tx arrange follow up at regular intervals coordinate w/ PCP and mental health providers Train staff for this work: on line (free!) or in person http: //impact-uw. org/training/web. html

Resources AAP: Addressing Mental Health Issues in Primary Care: A Clinician’s Toolkit http: //www. aap. org/commpeds/dochs/mentalhealth/Key. Resources. html Guidelines for Adolescent Depression in 10 Care: Glad - PC http: //www. glad-pc. org/ Teen. Screen: National Center for Mental Health Checkups http: //www. teenscreen. org/programs/primary-care IMPACT: Evidence based depression care: http: //impact-uw. org/ NAMI: resources for pts, families, providers http: //www. nami. org/ Heard Alliance: Collaborative of primary and mental health providers in SF Bay Area Peninsula www. heardalliance. org AACAP and APA: Resource Center and Parents Medication Guide www. aacap. org; www. psych. org Youth Bipolar Foundation of Northern Calif (YBFNC) ybfnc. cfsites. org Child & Adolescent Bipolar Foundation (CABF) www. bpkids. org Depression & Bipolar Support Alliance (DBSA) www. dbsalliance. org American Foundation for Suicide Prevention (AFSP) www. afsp. org

Current Research Studies at Stanford’s Pediatric Mood Disorders Program • Offspring of Parents with Bipolar and Major Depressive Disorders (Mechanisms of Risk and Resilience) – Studying offspring both with and without mood problems – Brain imaging (f. MRI, MRS, DTI) – Genetics • Clinical trials of safety and benefit of medications to treat symptoms of mood and attention in children • Studies of effects of mania & depression on developing adolescent brain • Psychotherapies and cognitive training for youth and families affected by depressive and bipolar disorders

Research referrals: Call Us: (650) 725 -6760 Email Us: PBDPStanford@gmail. com Our website: Pediatric. Bipolar. Stanford. Edu