Pediatric Depression and Suicide: An Update for School Nurses W. Burleson Daviss, MD Dept.
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Pediatric Depression and Suicide: An Update for School Nurses
W. Burleson Daviss, MD Dept. of Psychiatry University of Texas Health Science Center at San Antonio
Objectives
Learn about burdens associated with pediatric depression and suicide Learn about strategies for assessing pediatric depression Genetic and social risk factors Clinical signs, comorbidity, differential diagnosis Assessment strategies in a school-based setting.
Discuss treatment options for pediatric depression (providing essential information for school nurses).
Symptoms of Depression- SIGECAPS :
S leep problems I nterests decreased G uilty, worthlessness E nergy problems C oncentration problems A ppetite problems P sychomotor activity problems: agitation or slowing S uicidal thoughts or behaviors
Types of Pediatric Depression
Major Depression: sad-irritable moods or decreased interests, + 4 other symptoms, 2 weeks duration, impairing Minor Depressions: Dysthymia : 2+ symptoms, 1 year duration Adjustment disorder with depression : fewer sxs and shorter duration, response to stress Depressive disorder not otherwise specified Bipolar depression
Mania Mnemonic
Markedly elevated or irritable moods and 3-4 GR:RAPID symptoms: G randiosity R acing thoughts R eckless pleasure-seeking behavior A ctivity increased (goal-directed) P ressured speech I nsomnia: decreased need for sleep D istractibility
Bipolar Disorders
Must have had at least 1 manic or near manic (hypomanic) episode Manic episodes must last 4+ days with markedly irritable or elated moods Depressed symptoms often last longer than manic symptoms
Bipolar Disorders in Children
Rapid cycles Mixed episodes Often occur with psychotic symptoms Positive family history of bipolar disorder
Prevalence in Youths
MDD: 2% in children, 8% in adolescents 20% by the end of adolescents have had at least one MDD episode Bipolar disorder: 1-2% 20-40% of patients with MDD become bipolar
Morbidity/Mortality of Unipolar and Bipolar Mood Disorders
Bipolar more severe risk than unipolar Both typically recur, with worsening severity Both have serious long-term impact: Scholastic Interpersonal Occupational Substance abuse Legal problems Suicide
Suicide: 3 rd Leading Cause of Death in Youths Ages 15-19 — U N I T E D S T A T E S, 2001 — CAUSE Accidents Homicide Suicide Cancer Heart Disease Congenital Anomalies Chronic Lower Respiratory Disease Stroke Influenza and Pneumonia Blood Poisoning # OF DEATHS 6646 1899 1611 732 347 255 74 68 66 57 1599 Anderson & Smith 2003 C.E14
Environmental factors
Traumatic exposure and other adverse life events Family conflicts Parental stress Peer problems School problems Are these a cause or an effect?
Heritability
How much of the disorder is due to inherited, genetic factors (Nature) as opposed to environmental factors (Nurture)?
Genetic Factors
Depressive disorders: 40% heritability 3X higher risk of depression in immediate family Bipolar disorders: 75% heritability 8X higher risk of bipolar disorder in immediate family 3X higher risk of depression in immediate family Family members of bipolar patients more likely to have unipolar than bipolar moods.
Pediatric Depression: Challenges of Assessment
Differential diagnoses: Anxiety Disorders
Separation anxiety: child fearful anticipating separation from parent, clingy, school avoidant Social phobia: reluctant to interact with peers or perform because of fear of embarrassment
Differential diagnoses: Anxiety Disorders, continued
Obsessive compulsive disorder: repetitive thoughts or behaviors, anxious/agitated when not able to do these, distressing and time consuming Panic disorder: intense panic attacks, brief and must sometimes occur without a specific trigger Generalized anxiety disorder: pervasive worries multiple things, physical complaints (insomnia, muscle tension, restlessness), irritability
Differential Diagnoses: Disruptive Disorders
Irritability limited to specific situations involving authority figure Oppositional disorders: child angry, irritable & defiant with adults’ limit-setting, deliberately breaks rules, avoids accepting blame Conduct disorder: more severe DBD, lying, stealing, vandalism, aggression to animals or people
Differential Diagnosis: ADHD
Problems in 1+ domains of symptoms Inattention: distractibility, disorganization, trouble listening Hyperactivity/impulsivity: restlessness, and the “butt-in-skies” Best discriminators: depressive cognitions > somatic/vegetative sxs
Comorbid Disorders
Most mood disorders co-occur with some other disorders (comorbidity) Comorbid disorders occur first Complicate recognition of mood disorder Reduce effectiveness of treatments Worsen psychosocial outcomes
Assessment Strategies for Pediatric Depression
Diagnostic Work Up: History
Review history of psychiatric symptoms Review medical problems Review family’s mental health history Assess child’s function at school, with peers, and at home Review stressors that may be contributing
Rating Scales
Allow collection of data from multiple raters (child, parent, teachers) Screen for depressive symptoms and other diagnoses Help to monitor course of mood disorder and response to treatment
Rating Scales: General Scales
Child Behavior Checklist, Teacher’s Report Form, Youth Self Report Child and Adolescent Symptoms Inventory, Adolescent Symptom Inventory Vanderbilt Parent and Teacher Rating Scales (see handout) Simple, easy to use and score Good screen for disruptive behaviors Spanish version available Available free on the web: http://devbehavpeds.ouhsc.edu/rokplay.asp
Vanderbilt Scales: Scoring
Scoring guide on handout Count the number of symptoms rated 2 or 3 in various sections Symptoms clumped by disorders ADHD: #1-18 ODD: #19-26 CD: #27-40 Anxious/depressed: 41-47 Functional assessment section: #48-55, count the performance items rated 4 or 5
Rating Scales for Depression
Beck Depression Inventory Children’s Depression Inventory Mood and Feelings Questionnaire (see handout) Parent- and child- versions, long and short forms Simple wording and structure Available free on web: http://devepi.mc.duke.edu
Spanish version for parents developed by our group
Mood and Feelings Questionnaire: Scoring
Useful to combine both parent and child ratings to see if there are at least 5 symptoms of depression reported as “True” Scores suggestive of possible major depression) Scores on long version > 24 Scores on short version > 7
Diagnostic Work Up: Mental Status Exam (MSE)
Activity level Spontaneity Eye contact Affect Mood How do you feel talking to this kid?
MSE: Thought Content
Self esteem Hopelessness Helplessness Delusions Hallucinations Suicidal thoughts or behaviors
Assessing for Suicide
Ask about suicide, and document you did Use matter of fact questions: “Sometimes kids with these sorts of problems may feel like they’d be better off if they were dead. Do you ever feel that way?” “Have you ever thought about killing yourself?” “Have you thought of ways you could do it?” “What would make you more (or less) likely to do it?”
Assessing Suicide Risk
Current mental health problems?
Positive and negative environmental factors?
Past history of suicide attempts?
Does the child have current intentions to suicide?
Lethality of methods considered?
Availability of methods considered?
Are there guns at home?
Treatment
Two Main Treatment Options
Psychosocial Pharmacological
Psychosocial Treatments
Supportive therapy Educate child and family, address contributing stressors, refer for assessment and treatment Cognitive behavioral therapy Depression result from cognitive distortions that can be corrected with training and practice Interpersonal therapy Uses the issues that come up in relationship with therapist to help child to cope more effectively
Antidepressants: Selective Serotoninergic Reuptake Inhibitors (SSRIs)
Fluoxetine (Prozac): FDA-approved pedi dep, well tolerated, slow onset of effects, good for noncompliant patients Sertraline (Zoloft): approved for pedi OCD, wider dose range, some GI side effects and activation Citalopram (Celexa), Escitalopram (Lexapro): often well-tolerated and effective; faster acting?
Fluvoxamine (Luvox): approved for pedi OCD, more drug interactions, less well tolerated Paroxetine (Paxil): No longer recommended in pediatric age range, withdrawal problems
Treatment of Adolescents with Depression Study (TADS)
NIH-sponsored study of adolescents with major depression Compared fluoxetine, cognitive behavioral therapy, and combination treatments versus placebo Antidepressants were more effective than therapy, especially for severe depression Combination therapy more effective and safe
CDRS:
Adjusted Means (ITT)
60 50 40 30 Baseline Week 6 Stage I Assessments
TADS Team (2004), JAMA
Week 12
292: 807-820
COMB FLX CBT PBO
Non-SSRI Antidepressants:
Bupropion (Wellbutrin): noradrenergic & dopaminergic, help pedi ADHD; risk of seizures Mirtazapine (Remeron): Useful for insomnia Duloxetine (Cymbalta): serotonin & noradrenergic effects Venlafaxine (Effexor): no longer recommended because of withdrawal symptoms Tricyclics: desipramine, imipramine, nortriptyline; helpful for insomnia and enuresis but not pedi depression; cardiovascular risks require ECG & plasma levels, fatal in overdoses
Depressed Child or Teen?
Those who qualify will receive:
Interview and Assessment
Physical Exams
Comprehensive Lab Analysis Medication
Resource Referral
Compensation available
Continued care if applicable
At the University of Texas Health Science Center at San Antonio, we are conducting a clinical research study using an investigational medication bupropion for depression in adolescents ages 11-18 weighing at least 66lbs.
Symptoms include:
•
Sad or irritable mood
•
Lack of concentration in school
•
Loss of interest or pleasure
•
Changes in appetite or weight
•
Fatigue or loss of energy
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Feelings of worthlessness
•
Feelings of hopelessness
•
Sleep Problems
Call us at 210-562-5400 for more information
FDA “black box” warning for Antidepressants, October 2004
Higher suicidality in first weeks on antidepressants: 4% on antidepressant medication vs. 2% on placebo Applies to all antidepressants in all age groups Need close follow-up early for emerging suicidal thoughts, worsening mood or other intolerable side effects
Why Use Antidepressants At All? US Epidemiological Studies, Ages 15-24 Anderson 2002, CDC Wonder 2003, USDHEW 1956, Vital Statistics U.S. 1954 –1978 C.E16.XX
2 Years After Black Box…
~10%
drop
in antidepressant prescriptions to adolescents from 2004 to 2005 ~20%
increase
in adolescent suicide rates in the US (from 7.3 to 8.2 per 100K) Hamilton et al. (2007), Annual summary of vital statistics: 2005. Pediatrics 119(2):345-359
David Brent, MD:
“The risk of emergent suicidality in children and adolescents receiving SSRIs is real-- but small .” Antidepressants help many more people than they hurt Brent DA (2004), N Engl J Medicine 351(16), p 1601
School Nurse’s Potential Role in Monitoring
Weekly assessments, especially early in treatment for new or worsening symptoms: Suicidal thoughts or behaviors Insomnia Agitation or irritability Depressed moods or mania Communication with the prescribing physician if there are any concerns
Dr. Brent: “The Risk of Doing Nothing”
“Families and clinicians must find the right balance between the risk of suicidality and [the] greater risk …that lies in doing nothing.” Brent DA (2004), N Engl J Medicine 351(16), p 1601
Summary
Pediatric depression a potentially devastating problem, if undiagnosed or untreated We’ve reviewed risk factors, signs and symptoms of pediatric depression and suicide We’ve discussed strategies for assessment and treatment, especially in school setting
School Nurses’ Key Role
Identification of children at risk for depression and/or suicide Offering education and support to children, parents, and staff at schools Helping families to weigh risks/benefits of various treatments and to follow through Helping clinicians to monitor children’s response to treatment
Potential Resources
Web-pages for parents: www.aacap.org
www.nami.org
www.moodykids.org
www.wpic.pitt.edu/research/CARENET/ Web pages for clinicians www.moodykids.org
www.wpic.pitt.edu/research/CARENET/
Thanks!!!
Appendices:
Vanderbilt Teacher’s Rating Scale Vanderbilt Parent’s Rating Scale Vanderbilt Parent’s Rating Scale– Spanish Version Child Mood and Feelings Questionnaire Parent Mood and Feelings Questionnaire Parent Mood and Feelings Questionnaire- Spanish Version Study flyer for UTHSCSA Depression Trial