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Don’t Let It Get You Down!
Managing Depression in
Primary Care
Rebecca Baum, MD, FAAP
Clinical Assistant Professor of Pediatrics
Nationwide Children’s Hospital
Columbus, OH
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Disclaimer
 Statements and opinions expressed are those of the author and not
necessarily those of the American Academy of Pediatrics.
 Mead Johnson sponsors programs such as this to give healthcare
professionals access to scientific and educational information
provided by experts. The presenter has complete and independent
control over the planning and content of the presentation, and is not
receiving any compensation from Mead Johnson for this
presentation. The presenter’s comments and opinions are not
necessarily those of Mead Johnson. In the event that the
presentation contains statements about uses of drugs that are not
within the drugs' approved indications, Mead Johnson does not
promote the use of any drug for indications outside the FDAapproved product label.
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Objectives
 Understand the presentation of depression and low
mood in pediatrics.
 Implement first-line strategies to manage depression
and low mood in primary care.
 Identify key system components necessary for
managing depression and low mood in the primary
care setting.
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Well Child Care Visit
Sarah is a 13-year-old who presents with her mother for a
well child care visit. As you ask about school and friends,
Sarah’s mother mentions that her grades have dropped
and that she is spending more time in her room. Sarah
keeps her head down and shrugs her shoulders when you
ask her questions. With the visit about to wrap up, you
ask Sarah and her mother if there is anything wrong.
Sarah looks down and her mother says,
“I don’t know…aren’t all teenagers like this?”
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 What happened?
 What should we do next?
 How could things go differently?
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Well Child Care Visit
Sarah is a 13-year-old who presents with her mother
for a well child care visit. Like all teens in your practice,
Sarah completes the Patient Health Questionnaire-9
(PHQ-9) Modified for Teens depression screener at the
start of the visit. The results are available to you as
you begin your visit.
Patient Health Questionnaire-9 for Teens
Sarah’s PHQ-9
score is 9
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Defining Features
 Low, sad mood or irritability
o Loss of interest
o Thoughts about dying
o Pessimism or hopelessness
 Changes in thoughts about oneself
o Loss of self confidence
o Guilt or low-self worth, over-focus on past errors
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Defining Features
 Somatic changes
o
o
o
o
Disturbed sleep
Disturbed appetite
Fatigue or loss of energy
Agitation or slowing of movement or speech
 Cognitive changes
o Trouble with memory/concentration
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Related Questions
 How long have you been feeling like this?
 Other stressors? Supports?
 Appetite and sleep?
 Drugs and alcohol?
 Thoughts of self-harm or harm to others?
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Asking About Self-Harm
 Have you ever felt so sad that you didn’t want to be
here anymore? Or wanted to die?
 Have you ever had a plan to hurt yourself?
 Have you ever hurt yourself?
 Are you thinking of hurting yourself now?
Risk Factors




Access to lethal means
Substance use
Family history
Recent trauma or stress
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Assess Level of Risk and Respond Accordingly
• Implement pre-determined office plan for mental
health emergencies.
• Review safety planning.
• Assist with linkage to services.
• Provide resources.
• Make a plan to follow up with the family.
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“Making the Diagnosis”
 Major depressive disorder
o ≥5 symptoms present for ≥2 weeks (≥1 symptoms
being low mood or decreased pleasure)
o Screeners can help clarify diagnosis
Presentations in primary care are more likely to be
subclinical and/or shorter in duration.
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Challenges to Diagnosis
 Stigma
 Over generalizations
o “Aren’t all teenagers like this?”
o “I’m not crazy…just a little stressed”
o “I’m sure it will pass…we don’t need any help”
 Varied presentations
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Sharing Your Impressions
 Make a clear transition from information gathering
to summing up.
o Ask the family what they think the symptoms might
mean.
o Briefly outline your reasoning and ask if you’ve
gotten it right.
o When possible, present your conclusions as a range
of possibilities.
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Giving Advice
 Be thoughtful.
o Ask for “permission.”
o Ask for their ideas.
 Offer your advice as a set of choices.
o Include their ideas.
o Think about short- and long-term plans.
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FIRST-LINE STRATEGIES TO TRY IN
PRIMARY CARE
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Psychoeducation
 Depression is a common and treatable problem.
 Depression often runs in families, probably for
many reasons.
 It is normal to feel “down” but when these
feelings get in the way of life, there are ways to try
to feel better.
 Physical symptoms can be linked with mood—they
are not “made up.”
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Cognitive/Coping Skills
 Recognizing ANTS
o Automatic Negative Thoughts that become habit and
lead to negative thinking
 Using positive “self talk” to change thinking patterns
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Problem Solving Skills
 Try to lighten the load.
 List and prioritize problems.
 Focus on small, specific steps.
Behavioral Rehearsal and Social Skills
 What things trigger mood problems?
o Identify emotional cues and talk them through.
o Plan and practice new responses.
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Behavioral Activation
 Plan short-term activities which give enjoyment or
build confidence.
 Practice healthy habits.
o
o
o
o
Exercise
Caffeine intake
Sleep patterns
Nutrition
An example…
So, what would
make it go
better?
Are there any
other things
people could
be thinking?
Exactly. What if you tried to
smile back? If you don’t get a
response, maybe they’re
having a bad day.
Lunch is awful.
Everyone is staring
at me. They all think
I’m stupid.
If I had someone to
sit with…and if
people didn’t stare
like I was stupid.
You mean like maybe
they had a fight with a
friend or failed a test?
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When to Consider Medication
 Significant impairment or distress
 Recurrent or persistent symptoms
 Inability to access psychosocial interventions
When to Refer





Longer duration or recurrent episodes
Lack of response to first-line treatment
Significant impairment
Environmental stressors
Use of drugs and alcohol
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Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRI
Starting Increments, Effective
Dose, mg
mg
Dose, mg
Maximum
Dose, mg
Fluoxetine
(Prozac®)
10
10-20
20
60
Sertraline
(Zoloft®)
12.5-25
12.5-25
50
200
5
5
10
20
Escitalopram
(Lexapro®)
Adapted from Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120(5):e1313–1326.
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US Food and Drug Administration Indications
 Anxiety disorders
o Sertraline (Zoloft®): age ≥6 for obsessive-compulsive
disorder (OCD)
o Fluoxetine (Prozac®): age ≥7 for OCD
 Depression
o Fluoxetine (Prozac®): age ≥8
o Escitalopram (Lexapro®): age ≥12
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Dosing Considerations
 Start low, go slow.
 Increase dose after 1-2 weeks, then monitor.
 Maximal effectiveness after 4-6 weeks.
 Continue for 6-12 months after symptoms resolve.
 Taper when discontinuing to avoid withdrawal effects.
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Contraindications
 Bipolar disorder
 Psychosis
Interactions/Precautions
 Use with caution in other serotonergic medications
 Serotonin syndrome
o Mental status changes
o Autonomic instability
o Tremor, myoclonus
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Adverse Event Monitoring








Nausea
Headaches
Dizziness
Insomnia
Activation
Bipolar switching
Sexual dysfunction
Suicidal thinking--?
http://www.glad-pc.org/
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Key System Components: A Screening Checklist
Processes




Documentation
Confidentiality
Emergencies
Care coordination
Skills
 Assessment
 Intervention
Resources
 Referral sources
 Consultation
 Patient education
BUCKEYE STATE PRIMARY CARE
Process Title:
Mental Health Crisis Plan
Purpose:
Procedure for a child who is from our office
that expresses thoughts of harm to self or
harm to others.
Procedure Steps:
PRESENT and IN OUR OFFICE
1. The provider is to evaluate, document, and determine if the child is in an
acute mental health emergency (i.e. expressing harm to self or harm to
others).
2. Referral to PIRC (Psychiatric Intake Response Center)
3. Security to be called (XXX-XXXX) to escort the child in a wheelchair to the
emergency room (ER).
4. The provider calls the ER – Comm Center (XXX-XXXX)
5. Clinical staff talk or walk down to share information with the ER triage
nurse.
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Resources
 Patient Health Questionnaire-9 (PHQ-9) Modified for Teens
http://www.thereachinstitute.org/images/GLAD-PCToolkit_V2_2010.pdf
 American Academy of Pediatrics (AAP) Addressing Mental
Health Concerns in Primary Care: A Clinician’s Toolkit
http://shop.aap.org/Addressing-Mental-Health-Concerns-in-Primary-Care-AClinicians-Toolkit
 AAP Pediatric Psychopharmacology for Primary Care.
http://shop.aap.org/Pediatric-Psychopharmacology-for-Primary-CarePaperback
 Brief Online Videos about Common Behavioral Health Problems
http://pediatriccare.solutions.aap.org/video-series.aspx?categoryid=41125
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Credits
 John Duby, MD; Larry Wissow, MD; and the Building Mental
Wellness Team
 Additional funding provided by National Institute of Mental Health
(NIMH) and the Duke Endowment
 Many thanks to our friends and colleagues who acted in the videos
and who took part in prior versions of the training
 North Carolina collaborators: North Carolina Psychoanalytic Society
(NCPS); North Carolina Academy of Family Physicians (NCAFP);
North Carolina Psychological Association (NCPA); National Alliance
on Mental Health (NAMI) of North Carolina; and Northwest Area
Health Education Center (NW AHEC)
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