Major Depressive Disorder

—One or more episodes of depressed mood or loss of interest or pleasure for at least ___ weeks with at least ____ or more depressive symptoms

—Change from previous function

—In children or adolescents instead of depressed mood it can be ______mood

—One or more episodes of depressed mood or loss of interest or pleasure for at least two weeks with at least four or more depressive symptoms

—Change from previous function

—In children or adolescents instead of depressed mood it can be IRRITABLE mood

Name the depressive symptoms.

How many do you need to diagnose?

Need 4 out of 5 to diagnose

—Sleep disturbance, hypersomnia or insomnia

—Interests, loss

—Guilt or feelings of worthlessness

—Energy, decreased

—Concentration, poor or indecisive

—Appetite, increased or decreased

—Psychomotor agitation or retardation

—Suicidal ideation

When do you start asking children if they hurt themselves?

How many children and adolescents will have MDD?

What is the second leading cause of death among college students?

WHat is the male to female ratio of MDD in children and adolescents?

What population of adolescent girls have higher rates?

—2-4% children, 8% o adolescents, lifetime prevalence 15%  (MDD), 50-75% of children are untreated, 70% will have MDD in adulthood

—Suicide is 2^nd leading cause of death among college students

—Male to Female ratio; 1:1 in children, 1:2 in adolescents (MDD)

—Latina adolescent girls have higher rates

—AA adolescent girls have higher rates when living in white neighborhoods

—WHO predicts depression will be second most burdensome disease by the year 2020

—Anxiety; 30-80%, may persist

—ODD, CD; 10-80%

—Substance use; 20-30%

—ADHD; 33%

—Learning disabilities and developmental disorders

—CA

—Pituitary tumors

—Thyroid disease

—Neurologic disease (esp. migraine)

—Infection

—Hormonal treatments (corticosteroids)

—CF

—Genetics/puberty

—Life events (loss, failure) ie freq failures

—History of abuse

—Sexual identity issues  (30% of suicides)- many due to gender identity disorder

—Parenting

—Peer environment/changing roles; ie bullying

—Poverty 

This is an MDD presentation in what population?

-irritable, low frustration tolerance

failure to thrive

school refusal, phobias

somatic complaints

social withdrawal

little verbalization of depression

This is an MDD description in what population?

adolescents

—Age and ability to communicate will affect how a child presents

—Note non-verbal cues, facial expression, posture

—Look sad, move slowly, speak in monotones, restricted affect

—Describe themselves in negatives; “I am dumb”  “Nobody likes me”  “I am bad”

—Grades deteriorate

—Drop out of extra curricular activities, school refusal

What do the following phrases mean?

—“bored”

—“poor grades”

—“improved grades”

—“go to bed at a reasonable hour”

—“everyone gets on my nerves”

—“chilling with my friends”

—“bored”=anhedonia

—“poor grades”= inability to concentrate/ sign of ADHD

—“improved grades”= social withdrawal

—“go to bed at a reasonable hour”

—“everyone gets on my nerves”=irritability and agitation

—“chilling with my friends”=smoking pot

Diagnostic Interview

—With child and parent separately if possible

—Presenting history, recent stressors

—Review of depressive symptoms

—Review of para-suicide or suicidal behaviors, ideation

—Review of anxiety symptoms, manic/hypomanic symptoms, mood stability (impulsivity)

—Family history of mental illness

—MSE- pervasive mood, affective range, psychomotor retardation/agitation, concentration/attention, negative cognitions, delusions/hallucinations, hopelessness (future focused?), suicidality

—Cognitive behavioral therapy (CBT)

—Interpersonal Psychotherapy (IPT)

—Education (patient and family)

—School and home based help

—Transcranial Magnetic Stimulation (TMS) and ECT??

—VS, LFT’s, TSH, CBC, ECG

—SSRI’s (black box warning)-suicidality/increase in suicidal thoughts-SSRI kicks in 2-3 weeks

FDA approved; fluoxetine (Prozac) MDD (>8yo), OCD (>7yo), start at 5 or 10mg titrate up slowly.  Max-30mg/daily. Taper to d/c.

escitalopram (Lexapro) MDD (>12yo) Max-20mg/daily. Taper to d/c.

PROZAC- you can just stop- don’t need to taper-start on 5 mg and titrate up- start week of 5 then increase to 10 and see how they do- see pt how they’re doing- give you akesthesia and GI issues- need to check in with pt properly- if pt is bipolar can push them over the edge

Talk about black box warning and recent study in Netherlands.

Paxil and Zoloft approved for OCD, Wellbutrin approved for ADHD.

Acute treatment for suicidality; in pt? Out pt? Pharm? Education? Family? Tox screen (Tylenol, ASA, TCA’s), Urine pregnancy test, UDS, TSH, CBC.

—Start with lowest dose, increase slowly

—Monitor weekly or biweekly, involve therapist

—If partial response increase gradually, if no response, try another SSRI, then SSNI

—Ask openly about suicidality along with other SE’s.

—Use parent medication guide (APA, AACAP)

—Watch for signs of hypomania

—Know when to refer to Child and Adolescent Psychiatrist

—Must obtain informed consent from parent and adolescent

What is your role as a PCP?

—Systematic screening

—Clinical identification

—Entry level pharmacological intervention (SSRI at moderate dose)

—Coordination of other providers (child psychiatrist if available and if needed, psychologist, therapist)