Depression: A Short Course
Learning Objectives
• To review the diagnostic criteria and clinical
reality of adolescent depression
• Perform a depression assessment, based on the
AAP-approved GuideLines for Adolescent
Depression in Primary Care (GLAD-PC)
• Analyze two clinical case vignettes
• Use standardized questionnaires as aids in
assessment of depression.
• To score and interpret standardized
questionnaires applied to case vignettes
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Major Depressive Disorder in
Adolescents: Common in the
Primary Care Setting
• Prevalence:
– Children: 2%--1:1 M:F
– Adolescence: 4-8%–1:2 M:F
Significant burden of illness on patients and families
• High rates of depression in primary care settings
•
(Cheung et al., 2007)
• 50% of youth with depression missed in primary
care settings (Chang et al., 1988, Kramer & Garralda, 1998)
• USPSTF recommends screening for depression in
adolescents in primary care
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Adolescent Depression – DSM-5
A. Five (or more) of the following symptoms for a 2-week
period and representing a change from previous
functioning; at least one of the symptoms is either (1)
depressed mood or (2) loss of interest or pleasure.
(1) Depressed mood. Note: In children and adolescents, can be
irritable mood.
(2) Diminished interest or pleasure in all, or almost all, activities
(3) Appetite and weight changes
(4) Sleep pattern disruption
(5) Psychomotor agitation or retardation
(6) Fatigue or loss of energy
(7) Feelings of worthlessness or excessive or inappropriate guilt
(8) Diminished ability to think or concentrate, or indecisiveness
(9) Recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide
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Adolescent Depression (continued)
B. The symptoms do not meet criteria for a mixed episode.
C. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
D. The symptoms are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication)
or a general medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by
bereavement, the symptoms persist for longer than 2
months or are characterized by marked functional
impairment, morbid preoccupation with worthlessness,
suicidal ideation, psychotic symptoms, or psychomotor
retardation.
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Depression Mnemonics
Sig: Energy CAPs
ABCDEFGHI
DEAD SWAMP
Sleep Disorder
Anhedonia (decreased
interest in activities)
Depressed mood
Interest Deficits
(anhedonia)
Bad mood
Energy loss or fatigue
Guilt (feelings of
worthlessness)
Concentration
Anhedonia
Energy deficit
Death thoughts
Death thoughts
Concentration problems
Energy deficits
Sleep Disturbances (+/-)
Appetite changes (+ or -)
Food intake changes
Worthlessness of guilt
Psychomotor retardation
or agitation
Guiilt/self-esteem
Appetite or weight change
Suicidality
Hyper/hypoactive motor
behavior
Mentation (concentration)
decreased
Insomnia
Psychomotor agitation or
retardation
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Adolescent Mood Disorders: DSM-5
• Major Depressive Disorder
• Persistent Depressive Disorder
• Depressive Disorder Unspecified
• Adjustment Disorder with Depressed Mood
• Later Units
– Bipolar Disorder – presented in Unit I
– Disruptive Mood Dysregulation Disorder – discussed
in Units I & J
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Guidelines for Adolescent Depression
in Primary Care (GLAD-PC):
Development Process
• Initial partnership between the Center for the
Advancement of Children’s Mental Health,
Columbia University and University of Toronto
• Focus groups: primary care providers, parents,
and youth (Toronto, and Montreal)
• Consensus Survey of PCPs, depression
specialists (MD, PhD)
• Systematic Evidence based Literature Reviews
• Consensus Workshop with 80 participants
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GLAD-PC Guidelines:
Identification/Surveillance
Systematically look for patients
with depression risk factors*
*Update March 2009: US Preventive Services
Task Force recommends universal SCREENING
for adolescents 12-18 y.o., when systems are in
place to ensure accurate diagnosis,
psychotherapy (CBT), and follow-up.
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Depression Risk Factors
• High family loading (family history of
depression)
• Stressors:
– Loss, abuse, neglect, trauma, ongoing conflict and
frustrations, divorce, death (family/friend)
• Co-existing disorders (e.g., anxiety,
substance abuse, ADHD, eating disorders),
• Medical illness (e.g., diabetes, asthma),
• Biological and sociocultural factors
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GLAD-PC Guidelines:
Assessment/Diagnosis
• PC clinicians should evaluate for
depression in high-risk children or
adolescents as well as those who present
with emotional problems as the chief
complaint.
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GLAD-PC Guidelines:
Assessment/Diagnosis
• Use diagnostic criteria established in the
DSM (IV, now 5)
• Use standardized depression tools
• Conduct direct interviews with the patients
and families/caregivers
• Assess functional impairment
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GLAD-PC Toolkit
(see www.GLADPC.org)
• Screening and Assessment:
– Screening/Assessment Tools
 Columbia DISC Depression Scale (CDS)
 Patient Health Questionnaire-Modified (PHQ-9)
 Kutcher Adolescent Depression Scale
 Beck Depression Inventory (not in toolkit)
• Administer depression screener (PHQ-9, CDS,
KADS, CES-D, BDI ($), CDI ($), Other)
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How to Recognize the
Moods of an Adolescent
HAPPY
DEPRESSED
EXCITED
ANXIOUS
MANIC
SUICIDAL
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Clinical Vignette – Jennifer
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Group Discussion - Jennifer
• Workbook G 1.1-1.7
• Review CDS-child. What does this score
mean?
• Review CDS-parent
• Review PHQ-modified. What does the score
mean?
• Review DSM-5 checklist. Does she meet DSM
criteria for MDD?
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Table Activity- Jennifer
1. Review her CGAS and score it as group.
2. On the flipcharts, your scribes will write:
– CGAS score as a single number or range
– Any required lab tests
–
Differential diagnoses
5 minutes!!
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Clinical Vignette – David
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Table Activity:
Using Assessment Tools
• See DAVID’s questionnaires (G 1.8 – 2.4)
• Your group has 7 minutes to:
– Review David’s Columbia Depression Scale (CDS) and PHQ-M.
Discuss his “scores” in the context of the vignette.
– Review David’s parental CDS. Discuss the results as they apply
to the vignette and what you know about teens.
– Reconcile the scales with the vignette.
– Fill out the clinician DSM checklist for David. Discuss each
criterion, in the context of the vignette, as present or absent.
–
SCRIBES - Please write on your flipchart:
1. Does David meet criteria for MDD? (Y/N)
2. Differential diagnoses for David?
3. David’s CGAS score?
Unit G: Short Course Depression
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Group Discussion
• Discuss together:
– What additional information do you want
before initiating the treatment planning
phase?
– Lab Tests?
– ROS and further focused PE?
– Additional sources of history/functioning
levels?
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Assessment Summary
• Screen all youth for depression, and carefully evaluate
all screen positives, other high-risk children and youth,
and those presenting with emotional problems as the
chief complaint.
• Assess for depressive symptoms based on diagnostic
criteria established in the DSM 5 or ICD 10; and use
standardized depression tools to aid your assessment.
• Conduct face to face interviews in combination with
standardized assessment tools, and use multiple
sources of information ( e.g. teachers, guidance
counselors) to obtain a comprehensive diagnostic
picture.
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REMINDER:
Please fill out Unit G
evaluation
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Getting it Paid For: Self-Study
Do you know how to code these cases so you
will get paid?
Do you know when to use these coding
variations?
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Jennifer’s Visit: Diagnosis

Major Depressive Disorder, Single
Episode, Mild: 296.21

Major Depressive Disorder. Single
Episode, Unspecified: 296.2
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Jennifer’s Visit: 99215

Complex Medical Decision Making:
– Medical Diagnosis: Extensive
– Data: Extensive
– Risk: High

History:
– HPI: 4+
– ROS: 10+
– PFSH: 2
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Jennifer’s Procedures:
96110



Columbia DISC Depression Scale
(CDS): Jennifer, Mother
Pediatric Health QuestionnaireModified: Jennifer
3 standardized rating scales
administered, scored and interpreted
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Jennifer’s Visit





99215-25
(3) 96127





99215
96127
96127-59
96127-59
99215-25
96127
96127-76
96127-76
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David Visit 1: Diagnosis

Major Depressive Disorder, Single
Episode, Moderate: 296.22
Major Depressive Disorder, Single
Episode, Unspecified: 296.2
(Other Suspected Mental Condition:
V71.09)

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David’s Visit: 99215

Major depressive disorder meets the
criteria for complex medical decision
making
• High risk for morbidity/mortality
• Laboratory or other diagnostic tests
requiring review (rating scales)
• Extensive differential dx. to consider
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David’s Visit: 99215

Complex Medical Decision Making:
– Medical Diagnosis: Extensive
– Data: Extensive
– Risk: High

History:
– HPI: 4+
– ROS: 10+
– PFSH: 2
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David’s Visit: Prolonged
Services, Too?
Visit took 53 minutes -13 minutes
longed than the 40 minutes expected
for 99215
 99354: Prolonged physician service in
office/out-pt. setting in excess of usual
service, first hour (30-74 minutes)
No prolonged service code. (See
Appendix)

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Telephone Care

This follow-up call would properly be
considered post-service work for the
visit.
– Discussing results of a test directly
obtained after the encounter
– Call was within 7 days of the encounter
and the next visit was within a few days of
the call
– See Appendix
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