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Presidential Address: Depression Awareness and Screening in Children and Adolescents

2018; Elsevier BV; Volume: 57; Issue: 1 Linguagem: Inglês

10.1016/j.jaac.2017.10.015

1527-5418

Karen Dineen Wagner,

Adolescent and Pediatric Healthcare

I am honored to highlight my presidential initiative at the opening plenary of the 64th Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP). As you know, my career focus has centered on mood disorders in children and adolescents, particularly major depression. My presidential initiative is to increase awareness of and screening for depression in children and adolescents. The prevalence rates of depression have been increasing in youth, with reported rates of 11% in adolescents.1Avenevoli S. Swendsen J. He J.P. Burstein M. Merikangas K. Major depression in the National Comorbidity Survey–Adolescent Supplement: prevalence, correlates, and treatment.J Am Acad Child Adolesc Psychiatry. 2015; 54: 37-44Abstract Full Text Full Text PDF PubMed Scopus (630) Google Scholar As child and adolescent psychiatrists, we know the devastating impact of depression on children’s emotional, social, and cognitive development. Friendships are lost, family conflict ensues, and academic failures occur when children and adolescents are depressed. We have witnessed their despair; for example, the depressed 9-year-old who says, “No one could ever love me,” and the depressed 14-year-old who looks at you with dulled eyes and says, “I am too empty to live.” We know that the typical duration of an episode of depression is 9 months, which is an entire school year. Of grave concern is the risk of suicide for youth with depression. As reported by the Centers for Disease Control and Prevention, suicide rates have increased steadily in the past decade, with the greatest increase for girls 10 to 14 years old.2Curtin S.C. Warner M. Hedegaard H. Increase in suicide in the United States, 1999–2014. NCHS Data Brief, No 241. National Center for Health Statistics, Hyattsville, MD2016Google Scholar Youth with depression are at risk for recurrent episodes of depression, comorbid psychiatric disorders, and medical conditions. Approximately 50% of teenagers with depression are likely to have a recurrence of depression. Youth with depression often have comorbid psychiatric disorders such as anxiety disorders, attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, eating disorders, and substance use disorders, which complicate the course and treatment of depression. The American Heart Association issued a scientific statement that major depression in youth is a moderate risk condition for accelerated atherosclerosis and early cardiovascular disease.3Goldstein B.I. Carnethon M.R. Matthews K.A. et al.Major depressive disorder and bipolar disorder predispose youth to accelerated atherosclerosis and early cardiovascular disease: a scientific statement from the American Heart Association.Circulation. 2015; 132: 965-986Crossref PubMed Scopus (308) Google Scholar Although we, as child and adolescent psychiatrists, are all too familiar with the outcome of untreated depression, it is important for the public to be more informed about depression in youth. We have a responsibility as the leading organization in children’s mental health to increase awareness of and screening for depression in children and adolescents. The US Preventive Services Task Force (USPSTF) reviewed the evidence on the benefits and harms of depression screening in children and adolescents and the accuracy of screening tests administered in primary care settings.4Siu A.L. on behalf of the US Preventive Services Task ForceScreening for depression in children and adolescents: US Preventive Services Task Force recommendation statement.Ann Intern Med. 2016; 164: 360-366Crossref PubMed Scopus (96) Google Scholar Based on their review, the USPSTF recommends screening for major depressive disorder in adolescents 12 to 18 years old. The USPSTF further recommends that screening be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The Patient Health Questionnaire (PHQ-A) was found to have the highest positive predictive value as a screening instrument.5Johnson J.G. Harris E.S. Spitzer R.L. Williams J.B.W. The Patient Health Questionnaire for Adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients.J Adolesc Health. 2002; 30: 196-204Abstract Full Text Full Text PDF PubMed Scopus (347) Google Scholar The PHQ-A has a reported sensitivity of 73% and specificity of 94%. Treatment of major depressive disorder that was detected through screening in adolescents was associated with moderate benefits, such as improvements in depression severity, depression symptoms, or global functioning scores. The USPSTF found no direct evidence of harms of screening for major depressive disorder in adolescents. The USPSTF found that current evidence is insufficient to assess the balance of benefits and harms of screening for major depressive disorder in children 11 years or younger. It was noted that data on the accuracy of major depressive disorder screening instruments in children are limited. With regard to depression screening intervals, the USPSTF found no evidence on appropriate or recommended screening intervals. However, repeated screening can be most useful for adolescents with risk factors for major depressive disorder. This presidential initiative on depression awareness and screening in children and adolescents will have a multipronged approach including education, expansion of the Depression Resource Center, and collaboration with professional organizations and government agencies. Education about the prevalence, symptoms, and course of depression in children and adolescents is an essential component of this initiative. Parents and their children are often unaware of the symptoms of depression. It is readily understandable why parents might not recognize the symptoms of depression in their children. Unlike some other illnesses, the symptoms of depression tend to evolve over time. Also, parents often view their children’s moodiness as a normal phase of development, which it could be. If a teenager is irritable and has less interest in doing previous activities, then the parent might think it is typical teenage behavior. If further symptoms develop, such as sleep problems and low self-esteem, then parents might have some concerns but hope that the symptoms will pass with time. When the teenager’s irritability disrupts family functioning, school grades decline significantly, or the teenager begins cutting or mentions suicidal thoughts, then parents tend to seek help for their teenager. In my experience, the time from symptom onset of depression to clinical evaluation is approximately 2 years. If parents were educated about the symptoms of depression in children and adolescents, then intervention could be earlier to decrease the likelihood of impairment for their children. When children appear physically ill, parents routinely ask their children if they feel sick. Parents should be encouraged to ask their children how they feel when their children’s mood seems different than usual. Parents also should be educated about risk factors for depression in their children such as a family history of depression, bullying, substance abuse, and child abuse. Teenagers often do not recognize the symptoms of depression or might not use the term “depression” to describe their mood. “Stressed out,” “bored,” and “nothing feels right” are common expressions used by teenagers with depression. If teenagers feel irritable, they tend to blame their irritability on the people around them, that is, other people are trying to annoy them. Teenagers often are not cognizant of the effects of their irritability on their interactions with other people. Depression symptoms such as sleep difficulties, feeling tired, and poor concentration can be attributed by teenagers to the demands of school work and activities. When teenagers reach the point of not wanting to do anything or start to think about suicide, then they are more likely to recognize that there is a problem with their mood. Teenagers need to know that they can talk to their parents, school counselor, or other responsible adult about their mood. I envision the AACAP online Depression Resource Center as the go-to place for clinicians, parents, youth, and organizations to obtain up-to-date evidence-based information about depression in children and adolescents. All information on the existing Depression Resource Center will be reviewed, updated, and expanded. The Practice Parameter for the Assessment and Treatment of Children and Adolescents With Depressive Disorders (last updated 2007)6Birmaher B. Brent D. AACAP Work Group on Quality IssuesPractice parameter for the assessment and treatment of children and adolescents with depressive disorders.J Am Acad Child Adolesc Psychiatry. 2007; 46: 1503-1526Abstract Full Text Full Text PDF PubMed Scopus (673) Google Scholar will be replaced by a planned Clinical Practice Guideline on the Assessment and Treatment of Depression in Children and Adolescents. Similarly, the Parents Medication Guide on the Use of Medication in Treating Childhood and Adolescent Depression: Information for Patients and Families (last updated 2010)7AACAPParents Medication Guide on the Use of Medication in Treating Childhood and Adolescent Depression: Information for Patients and Families. Author, Washington, DC2010Google Scholar will be revised and updated. The Depression Resource Center will have sections related to depression in children and adolescents as follows: Facts for Families; Frequently Asked Questions; Parent Medication Guide on Depression in Children and Adolescents; Clinical Practice Guideline on Assessment and Treatment of Depression in Children and Adolescents; Screening Instruments for Depression; Clinical Rating Scales for Depression; Major Studies and Publications on Depression in Youth; and links to other professional organizations and resources. In addition, I would like a section to be developed for teenagers to help increase their understanding of depression, treatment, and resources for help. Development of a Facts for Teenagers on Depression and Frequently Asked Questions by Teenagers such as “What should I do if I’m feeling down?” will be components of this section. To promote depression awareness and screening in children and adolescents, it will be important to collaborate with other national organizations and agencies that deal with children’s mental health issues. As part of this initiative, AACAP will initiate engagement with organizations such as the American Psychiatric Association, American Academy of Pediatrics, American Academy of Family Physicians, American Psychological Association, American Foundation for Suicide Prevention, National Alliance on Mental Illness, Depression and Bipolar Support Alliance, National Institute of Mental Health, and Substance Abuse and Mental Health Services Administration, among others. With the support of these organizations, it is more likely we will achieve the goal of depression screening as routine health assessment for youth. I have appointed a Presidential Task Force to work with me on this initiative. There is wide representation from AACAP committees including Healthcare Access and Economics, Consumer Issues, Advocacy, Quality Issues, Research, Psychopharmacology, Health Prevention and Promotion, Program, and Web Editorial Board. This initiative will further evolve with input from the Task Force members. I invite you, as Academy members, to join me in the effort to raise public awareness of depression in children and adolescents and to promote routine screening for depression in youth.