Young people should be screened for depression, in accordance with existing guidelines, and primary care clinicians should have the tools in place to identify and treat patients who may be suffering from depression, according to the American Academy of Pediatrics (AAP).
In their first update to depression guidelines in 10 years, the AAP endorsed “universal adolescent screening for depression in children ages 12 and over,” which had already been recommended by the academy, stated Dr Rachel A Zuckerbrot, of the AAP Guidelines for Adolescent GLAD-PC Steering Group, and colleagues.
The guidelines are in two-parts, with the first focusing on identifying, assessing, and diagnosing depression, and the second on treatment and management of depression. Both guidelines included varying strengths of recommendations, but graded the evidence for those recommendations from 1 to 5 (strongest to weakest). The first policy statement focused on the identification, assessment, and initial management of depression. The strongest evidence (grade 1) exists for using standardised depression tools to aid in the assessment of depression and assessing “functional impairment” in different domains and other existing psychiatric conditions,
But there is also grade 2 or 3 evidence for “direct interviews with the patients and families and/or caregivers” in assessing the patient, as well as assessing for symptoms on the basis of criteria used in the DSM-5 or the ICD-10. There is also evidence for establishing a safety plan about how to handle “increased suicidality after acute cases,” including an emergency communications mechanism.
The following evidence was graded at the lowest level (grade 5), but nonetheless received “strong” or “very strong” recommendations from the authors in terms of how clinicians should identify, assess, and diagnose patients with depression: seek training in depression assessment, identification and diagnosis; establish referral and collaborations with mental health resources in the community; and develop a treatment plan with families and set treatment goals for home, peer, and school settings.
The authors acknowledged that because primary care clinicians will have varying degrees of training in terms of identifying and diagnosing depression, “a good deal of time and flexibility will be required before these guidelines are adopted systematically or as a universal requirement.”
The second part of the guidelines by Dr Amy H Cheung, also of the GLAD-PC Steering Group, and colleagues, addresses the treatment and ongoing management of depression. The strongest evidence (grade 1) was for “tested and proven treatments,” such as psychotherapy (including cognitive behavioural therapy or interpersonal psychotherapy for adolescents), or antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) to achieve the goals of the treatment plan. Primary care clinicians “may consider sharing care with mental health agencies and/or professionals where possible,” they noted.
Grade 2 and 3 evidence also exists for clinicians considering “a period of active support and monitoring before starting evidence-based treatment” immediately after diagnosis. Also, clinicians should monitor for the emergence of adverse events if a patient is treated with SSRIs.
Some evidence on treatment plans was graded at the lower levels (grades 4 and 5), but still received “strong” recommendations from the authors about how clinicians should treat and manage patients with depression: work with administration to reflect best practices in integrated and/or collaborative care models; consult with a mental health specialist if complicating factors, such as substance abuse or psychosis, are identified; patient and family should be “active team members” and approve roles of primary care and mental health clinicians; systematic tracking of goals and outcomes from treatment, including symptom monitoring; and diagnosis should be reassessed after no improvement noted after 6 to 8 weeks of treatment.
When discussing future directions for treatment and management of depression, the authors noted that “ample evidence exists to support the notion that guidelines alone are insufficient in closing the gaps between recommended versus actual practices.” This makes research into new methods of disseminating information, which can provide assistance to primary care clinicians who manage depression in their practices that much more necessary, they stated.
Objectives: To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings.
Methods: By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience.
Results: Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan.
Conclusions: This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.
Rachel A Zuckerbrot, Amy Cheung, Peter S Jensen, Ruth EK Stein, Danielle Laraque, GLAD-PC STEERING GROUP