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Considering and Starting Treatment for Depression & Anxiety

Abigail Schlesinger MD

Goals and Objectives

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At the completion of this program, participants should be able to:

1. Recognize the importance of the behavioral health differential diagnosis when prescribing medication for depression/anxiety

2. Describe a method to deploy components of their behavioral health toolbox(therapy strategy, safety plan, and/or medication)

3. Recognize the importance of appropriate follow-up for behavioral health interventions provided in pediatric primary care

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Therapeutic Toolbox

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Follow-up

Non-medication Interventions

Safety Planning

Medication

Referral and Coordination

Nonmedication Interventions

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Relationship

HELLPP Skills

Assessment

Health Behavior Interventions

BH Interventions

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Organizing the Session

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Set Agenda

Recognize frustration/fears/anger/strengths & instill hope

• Listen and Ask targeted questions sleep, appetite, routines, school, friends, mood, hope/helplessness

Clarify Needs(assessment, differential, safety planning)

• I understand you are here for depression. Today I am going to ask questions and listen to you so that I can better understand your concerns.Then we will come up with initial goals/strategies to improve your mood

Create clear plans

GAD-7

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PHQ-9

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Depression: Assessment with SIG-E-CAPS

Depressed and/or irritable mood PLUS….

Sleep problem(up or down)

Interest deficit (anhedonia)

Guilt (worthlessness, hopelessness, regret)

Energy deficit

Concentration deficit

Appetite changes(up or down)

Psychomotor agitation or retardation

Suicidality

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DSM 5 Criteria: Major Depressive Disorder

1. Sad, down, negative mood, empty feeling, hopelessness, irritability in children

2. Anhedonia, decreased interest or loss of pleasure

3. Changes in sleep

4. Changes in appetite

Irritable, easily frustrated, argumentative. Focused on negative events, interprets events as negative, discounts positives. “I don’t care” attitude

Not enjoying or quitting activities; Subjective report or observed by others

May sleep/eat more or less.

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DSM 5 Criteria: Major Depressive Disorder

5. Decreased concentration,

decisiveness

6. Psychomotor agitation or

retardation, observable by others

Easily swayed by others, changes mind, may question if developed ADHD, amotivation

Complaints of feeling agitated, noted pacing/ increased negative energy, or “couch potato”, amotivation

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DSM 5 Criteria: Major Depressive Disorder

7. Complaints of fatigue or

decreased energy

8. Feelings of

worthlessness or

excessive/inappropriate

guilt

9. Death wish, suicidal

ideation

Regardless of increased or decreased sleep

Negative about self, low self esteem, may feel responsible for events out of their control, discount positives and focus on negatives

May think family would be better off without them for fleeting moments or chronically think life isn’t worth it, want to hurt self but no plan, or have a plan, and/or intent

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DSM 5 Anxiety Disorders• Generalized Anxiety Disorder

• Social Anxiety Disorder

• Separation Anxiety Disorder

• Selective Mutism

• Specific Phobia

o Animal, natural environment, blood-injection-injury, situational, other

• Panic Disorder

• VS Panic as a part of depression

• Other Specified Anxiety Disorder

• Also consider: Somatoform Disorder, OCD

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Anxiety: Developmental Issues

Preschool=predominantly separation

School age=worries decrease for separation and focus on performance

Adolescents=worries of peer acceptance

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DSM 5 Criteria: Generalized Anxiety Disorder

Diagnostic Criteria Clinical Pearls

• Essential feature is

excessive worry

(apprehensive

expectation, fear of the

future) more days than

not for at least 6 months

• Worries are difficult to

control

• These kids can worry

about the fact that they

worry.

• If they’ve had it their

whole life they might not

see it as a problem,

even though their entire

family alters their life to

help

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DSM 5 Criteria:Generalized Anxiety Disorder Diagnostic Criteria Clinical Pearls

• In children, must have one of

the following:

o c/o restlessness

o easily fatigued

o difficulty concentrating

o irritability

o muscle tension

o sleep disturbance

• Be alert for this diagnosis

when a child and/or

family is concerned

about ADHD but the

teacher reports only

minimal inattentive

symptoms.

• Teachers often love

these kids.

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GAD: Assessment

Most common anxiety disorder diagnosis

Screening questions Would you describe yourself as a worrier?

Ask the kid or parents about bedtime.

“What if” questions

Give examples of common worries—the weather, robbers, grades, terrorism, health concerns.

Ask teens if they worry about their future

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DSM 5 Criteria:Social Anxiety Disorder Diagnostic Criteria Clinical Pearls

• Anxiety caused by exposure to a feared social situation

o Exposed to scrutiny

o Must include peer settings

o Fear of embarrassment/rejection by peers

• Attempt to avoid social situations or endure at great distress

o Children may cry, tantrum, freeze, or shrink from the exposure

• Symptoms present for at least 6 months

• May take a bad grade or skip school in order to avoid situation.

• Doesn’t mean that they are not social…they must have some age appropriate friendships.

• Will overuse texting/internet for communication

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SAD: Assessment• Would you describe yourself as shy?

• When you are around your peers, do you worry about

saying the wrong thing? Getting embarrassed?

• Will you raise your hand in class?

• Will you order food at a restaurant?

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DSM 5 Criteria: Separation Anxiety Disorder

3+ of the following symptoms are present:

Distress with separation or anticipated separation

Worry about losing caregiver or harm coming to them

Illness, injury, disasters, death

Worry of untoward event causing separation

lost, kidnapped, illness

Physical complaints w/ separation or anticipated separation

Headaches, stomachaches. Sunday nights.

Persistent reluctance to leave home because of fear of separation

Persistent reluctance to sleep away from home or sleep without having caregiver near

Repeated nightmares of separation

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DSM 5 Criteria: Separation Anxiety Disorder Onset from preschool until 18 years of age

Duration at least 4 weeks

Developmentally inappropriate worry related to separation from home or to

whom one is attached

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Separation Anxiety Disorder: Assessment • Question parents but sometimes children may have insight.

• Ask about difficulties separating in general. Start with younger years—

preschool, school age.

• Ask how they did in preschool/kindergarten separating from parents

• Where do they sleep? Do they sleep alone?

• Will they go on overnights/sleepovers?

• History of separation anxiety increases risk of other anxiety disorders.

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DSM 5 Criteria: Panic Disorder Recurrent, unexpected panic

attacks

Panic attack: an abrupt surge of

intense fear that reaches peak

within minutes

4+ symptoms

Attacks followed by 1+ months:

Persistent concern/worry about

more panic or their

consequences

Significant, maladaptive change

in behaviors

Chills or flushed

Dizzy, unsteady,

light-headed

Derealization depersonalization

Sweating Chest pain

Choking Palpitations, fast HR

Shaking GI distress Fear of dying

Fear of losing control/”going

crazy”

SOB, suffocating Paresthesias

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Panic Disorder: Assessment

• Have you ever had a panic attack?

o Describe it.

• Have you ever had anxiety so extreme that you noticed symptoms in your body?

• How long did it last?

• Are there precipitants?

• Are you avoiding certain things out of fear of having another panic attack?

• Panic disorder vs. panic attack specifier.

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SCAReD Scoring

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Initiation

Check(s)

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1.Validate Diagnosis & Safety

2.Review Family History

3.Complete Consent/Assent

4.Clarify

Goals/Expectations/Safety Plan

5.Start Medication

6.Schedule follow-up

1. Validate Diagnosis & Safety

Review work-up - medical diagnosis & comorbid psychiatric

ASSURE SAFETY

Confirm Diagnosis

Review Behavioral Scales

SCARED parent and child(7-18) or GAD-7(13 and over 18)

PHQ9(or PHQ9a)

Consider Comorbidities that can Complicate Treatment

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Consider Psychiatric Comorbidities that

Could Complicate Treatment

Bipolar Disorder

Autistic Spectrum Disorder

Trauma

Substance Use

Eating Disorder

Suicidality

ADHD & ODD

Assess personal history

Are ASD driving “anxiety behaviors”

Acute or Chronic Trauma

Consider Substance Screen

Medication won’t work if you don’t have enough food to feed the brain

Assess past and Current

Consider Vanderbilts

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Screening for Bipolar Disorder

“Was there ever a period of time, for more than a few days, that you(or

your child) didn’t need sleep, was on top of the world, and significantly

different than usual”

Note

This should be a clear change from baseline.

Child should be energetic during the day, ie not need a nap, not go to bed early

There is the most concern for bipolar disorder if the child was euphoric(more

happy than normal) or grandiose(felt that they were special, had special powers

etc) and there is no reason for it(ie it’s not the day before a holiday)

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Safety

Safety should be assessed in all

children and adolescents

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Depression & Suicide

Untreated depression is the number one cause of suicide

Over 90% of children and teens who complete suicide have a mental health diagnosis (Mental Health: A Report of the Surgeon General)

Suicide is the #2 cause of death in the U.S. in those 10-24 years-old (NCHS)

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Risk Assessment

Begin with general questions: “Have you ever thought you would be better off

dead….your family would be better off without you”

Death wish: 20% prevalence

Progress to more specific questions: “Have you ever had a plan?” Means to

carry out?

Much less common

Gave away possessions?

Normalize:

Many times children who are feeling down or depressed describe having

thoughts that they don’t want to be alive. Have you ever felt that way?

Self-Injury and Suicidal behavioral

Having self-injury is risk-factor for suicide

There is a continuum from superficial self-injury to a suicide attempt

It is important to be able to differentiate in order to assess current risk

Most-often people can tell you that they were harming themselves to

Kill themselves and/or

Harm themselves(often described as coping mechanism to deal with psychological pain)

Ask what their method of self-injury is(where and with what)

Must ask about plans when kids have thoughts of suicide (even if they say “I would never

do it”)

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2. Review Family History

Bipolar Disorder

Response to Antidepressants

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3. Consent/Assent

Parent should consent

Adolescent(and preferably child) should assent

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Consent/Assents Warn about side effects

More common that will probably go away if not too

bothersome(if they even occur)

Rare and concerning

Suicidality

Mania

Serotonin Syndrome

Other

Activation – some kids get increased energy during

the day, but have no trouble with sleep

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SSRI Side Effects

• GI: nausea, abdominal pain, diarrhea, weight loss,

weight gain

• Headaches

• Easier bruising

• Sweating

• Light-headedness/dizziness

• Nervousness/restlessness

• Sleep difficulties: sedation/insomnia, vivid dreams

• Sexual dysfunction

• Irritability/activation

• Potential risk for suicidal thinking

• Precipitation of mania38

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FDA Black Box Warning

Based on a 2004 FDA review of reported adverse events

in 23 clinical trials which involved 4300 children and

adolescents, 9 different medications

Studies used two different measures for suicidal thoughts

and behavior

FDA clumped both thoughts and behaviors as “suicidality”

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FDA Black box

First measure “event report”

Second measure – 17 of 23 studies “standardized forms”

questioned suicidality at each visit

Second measure technique considered more accepted

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FDA Black Box warning

Studies that used event reporting noted that 2% who

received placebo expressed increased suicidality

compared to 4% on medication.

Studied that used standardized forms that questioned

suicidality at each visit demonstrated a slight reduction

in suicidality for the medication group.

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Black Box Warning

“Less than 2% of kids who start an SSRI will see an

increase in suicidality – often suicidal thoughts/ &

thoughts about self-injury. I am recommending this

medication because the benefits of treating this

depression/anxiety far outweigh any risk associated with

increased suicidality. But, because we take behavioral

health seriously I will follow-up with you closer while

starting medication to make sure that you are safe.”

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4. Clarify Goals/

Expectations/Safety

GOALS

What does the family/child want to get out of treatment?

Do you anticipate that this intervention will help?

Are goals aligned with treatment

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Clarify Expectations: Roles

Providers in the practice

Help design & support the treatment plan that includes

evidence-based intervention

Maintain confidentiality, with caveats

Help child/adolescent get better

Parents & Patients

Participate in treatment

Help design and support the treatment plan

Speak up if things aren’t going well

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Expectations of Treatment

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Expectation of Treatment

Getting better takes time

SSRIS take time – 4-12 weeks at therapeutic dose

Dose may need to be adjusted over time

So response needs to be monitored

Treatment works better if you participate in therapy

Safety Plan

1. Coping strategies

2. Adult(s) who child will contact if distressed

3. Emergency numbers

Write the plan down

Share with the family

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Safety Plan

1. Coping strategies

2. Adult(s) who child will contact if distressed

3. Emergency numbers

Write the plan down

Share with the family

5. Start Medication

You can increase medication weekly

You can start at typical starting dose or low starting dose

We often start at low dose for kids with a lot of

anxiety, somatic symptoms, young kids, or kids with

developmental concerns

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Choose a medication

Factors to consider in choosing

Fluoxetine has the most data

Sertraline has more data for anxiety

If you have any concern about bipolarity don’t use

Prozac

Celexa has histaminergic properties – helps belly pain

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SSRI Titration Schedule

Medication Low

Starting

Dose

Typical

Starting

Dose

Typical

Effective

Dose

Typical

Dose

Range

Typical

Escalation

amount

Fluoxetine 5mg 10mg 20mg 60mg 10mg

Sertraline 25mg 50mg 100-150mg 200mg 25mg

Citalopram 5mg 10mg 20mg 40mg 10mg

Escitalopram 2.5mg 5mg 10mg 20mg 5mg

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SSRI General Information

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Medication Typical

Effective Dose

Typical Dose

Range

Half-life Half-life of Active

Metabolites

Fluoxetine 20mg 60mg 2-3 days 2 weeks

Sertraline 100-150mg 200mg Males – 22.4

hours

females 32-

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NA

Citalopram 20mg 40mg 20-35 hours NA

Escitalopram 10mg 20mg 20-35 hours NA

FIRST SSRI

CHECK

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When

1-2 Weeks after starting medication

1.Check Side Effects

2.Check for Response

3.Review Expectations/Goals/Safety

4.Increase medication(if you started low)

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FIRST SSRI CHECK

We don’t expect clinical response yet.

So condition may continue to worsen

This check is predominantly to check

Side effects

Assure safety

Get medication to therapeutic dose

(Have a check in – in case it appears a higher level of care is needed)

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FIRST SSRI Check Check side effects

“Are you concerned about side effects? Has anything changed that you are worried might

be related to medication”

“Have you had any thoughts about hurting yourself or anyone else?”

Check for response

“How are you doing?”

“On a scale of 1-10, 10 being as good as you could feel, how are you doing?”

Review goals

“Are you still hoping to work on ___”

Review safety plan

“Have you had to use your safety plan? Or How close have you come to using your safety

plan? Do you still feel like you could use your safety plan”

“Could you repeat your safety plan?”

Review expectations

“It’s early to see an impact of medication but you should see some positive response in 2-

4 weeks.”

“We look forward to your next check-in in 1-2 weeks”

Increase medication (if you started low) 54

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First SSRI Check

1. Check Side Effects

Are you concerned about side effects? Has anything changed that you are

worried might be related to medication”

“Have you had any thoughts about hurting yourself or anyone else?”

2. Check for Response

How are you doing?”

“On a scale of 1-10, 10 being as good as you could feel, how are you doing?”

3. Review Expectations/Goals/Safety

4. Increase medication(if you started low)

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First SSRI Check1. Check Side Effects

2. Check for Response

3. Review goals

“Are you still hoping to work on ___”

→ Review safety plan

“Have you had to use your safety plan? Or How close have you come to using

your safety plan? Do you still feel like you could use your safety plan”

“Could you repeat your safety plan?”

→Review expectations

“It’s early to see an impact of medication but you should see some positive

response in 2-4 weeks.”

“We look forward to your next check-in in 1-2 weeks”

4.. Increase medication (if you started low)

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Ongoing Follow-up

General Comments

Remember these medications

actually work slowly

4 weeks for depression

Up to 12 weeks for anxiety

Assure patient has frequent

follow-up until getting better

And then at least monthly follow-

up until in full remission

What to do other than “how

have things been going”

1. Check Side Effects

2. Check for Response(GAD7, PHQ9)

3. Review Expectations/Goals/Safety

• Are expectations too high(or low)?

• Are their roving expectations?

4. Increase medication and/or

psychotherapy if not in full remission

and not generally improving weekly

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Thank-you!

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