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Adolescents can benefit from early screening and treatment of major depressive disorder initiated in their pediatrician’s office, according to a new draft recommendation from the US Preventive Services Task Force.
Major depressive disorder (MDD) is 1 of the most common mental illnesses and a leading cause of disability, unfortunately it’s not a disorder that limits itself to adulthood. An estimated 2.6 million adolescents aged 12 to 17 years-10.7% of that population-suffered at least 1 depressive episode in 2013, according to the National Institutes of Health (NIH).
Now, the US Preventive Services Task Force (USPSTF) is recommending that adolescents aged 12 to 18 be screened for MDD and offered treatments including pharmacotherapy. There is insufficient evidence to consider screening and such interventions in children younger than age 12, says USPSTF.
Major depressive disorder can present with a number of symptoms-ranging from sadness and anhedonia to suicidal ideation-that last more than 2 weeks and impair the adolescents normal functioning and development. In addition to impairing daily functioning, MDD can also negatively affect developmental trajectories and lead to recurrent depression, other mental disorders, and increased risks of suicidal ideation, attempts, or completion.
The task force found that adolescents that were screened and identified within their primary care setting as having MDD and provided treatment reported improved depression symptoms and daily functioning.
“Because they are often the first point of contact for children and their families who are experiencing distress, pediatric care providers can facilitate early identification of mental health issues, begin initial management, and refer children for further assessment and treatment for mental health,” according to USPSTF. “Pediatricians, however, tend to be highly specific in assessing emotional and behavioral problems (eg, 84% of children assessed as non-disturbed in fact did not have a psychiatric disorder in 1 study) but not very sensitive (eg, pediatricians identified only 17% of children with behavioral or emotional problems as such).”
The etiology of MDD isn’t fully understood, says USPSTF, but can include genetic, biologic, and environmental factors. Family history, other mental illnesses, childhood abuse or neglect, conflicted sexual orientation, low socioeconomic status, and family conflicts are all possible contributors to MDD development. Some symptoms of MDD that might alert a pediatrician or primary care physician to an MDD diagnosis include sleep and appetite disturbances, unspecified pain, headaches, and stomachaches.
Adolescents with depression are also more likely to have other mental health problems, says USPSTF. About two-thirds of adolescents with depression have at least 1 comorbid psychiatric disorder, and 10% to 15% have 2 or more other psychiatric disorders in addition to MDD. The most prevalent comorbid disorders included conduct disorder/oppositional defiant disorder, anxiety disorder, and attention-deficit disorder. Adolescents with MDD are also at higher risk of developing a substance abuse disorder-USPSTF says anxiety disorders typically precede adolescent depression symptoms whereas substance abuse disorders follow depression onset by 4 to 5 years. The USPSTF also notes that 61% of adolescents eventually diagnosed with bipolar disorder initially presented with depressive episodes and were not diagnosed with bipolar disorder until later when a manic episode occurred.
There are numerous screening methods developed for use in primary care, including the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI), says USPSTF. The PHQ-A has the best results when compared to a full mental health assessment, according to USPSTF. No optimal interval for screenings has been found to be most productive and opportunistic screenings may be the most appropriate for adolescents who typically have infrequent visits to their primary care physicians.
As far as screening in children aged younger than 12, USPSTF says there is little evidence in harm aside from costs and potential stigmas. The mean age of MDD onset is 14 to 15 years-earlier in girls that in boys-and early onset is often associated with worse outcomes, notes USPSTF. Additionally, 10% of children aged 5 to 13 years who were diagnosed with MDD attempt suicide, and that number rises to 19% in adolescents aged 13 to 18 years, says USPSTF. With only 36% to 44% of those populations receiving treatment for depression, USPSTF suggests the majority of depressed youths are “undiagnosed and untreated.”
Treatment options can include psychosocial support, collaborative care, psychotherapy, and pharmacotherapy-although the US Food and Drug Administration (FDA) has only approved fluoxetine and escitalopram to treat MDD in adolescents. However, FDA has also issued a black box warning for antidepressants, stating that patients starting antidepressant therapy must be monitored and observed for worsening symptoms, suicidality, or unusual behavior changes.
This review updates USPSTF’s 2009 recommendation, which endorses screening when systems are in place for accurate diagnosis, psychotherapy, and follow-up. The new recommendation adds additional therapies, including pharmacotherapy.
“The task force cares deeply about helping young patients grow into healthy adults and examined the evidence on screening all children for MDD to determine if screening and treatment could improve health outcomes,” says Alex R. Kemper, MD, MPH, MS, USPSTF member, board-certified pediatrician and professor of pediatrics at Duke University Medical School, and associate division chief for research in the Division of Children's Primary Care at Duke University. “The evidence showed that young patients aged 12 to 18 who were screened for depression and identified as having MDD experienced improved depression symptoms and daily functioning after treatment, and recommends that clinicians screen these adolescents when adequate systems are in place for diagnosis, treatment, and monitoring.”
The updated recommendation echoes that of Medicaid, American Academy of Pediatrics’ Bright Futures program-which states that children and adolescents should be screened for emotional and behavioral problems annually-and the American Academy of Family Physicians (AAFP). The AAFP’s recommendation mirrors USPSTF’s original 2009 review.
“This recommendation is intended to empower clinicians and patients with the latest evidence on depression screening in children and adolescents to make informed decisions about ways to detect MDD,” Kemper says. “The evidence shows screening for depression is effective in young patients aged 12 to 18. Primary care providers who do not regularly screen teens for MDD should strongly consider developing a system to do so and to provide care for those with a positive screen.”