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Too many children with depression go undiagnosed and untreated, according to the American Academy of Pediatrics. Updated guidelines should address this standard of care.
Only about half of teenagers with depression receive a diagnosis before they become adults, and about two-thirds go without help, according to a report that has spurred the release of revised guidelines on depression screening and management for children from the American Academy of Pediatrics (AAP).
The updated guidelines, GLAD PC (Guidelines for Adolescent Depression in Primary Care), include a new recommendation that all children aged older than 12 years be screened for depression at least once per year.1
Rachel Zuckerbrot, MD, a board-certified child and adolescent psychiatrist and associate professor of Clinical Psychology at Columbia University, New York City, and coauthor of the report, also helped to craft the AAP’s updated guidelines. She says the report and the guidelines highlight the need to address mental health in pediatric well-child care.
“I think it is important for pediatricians to know that the American Academy of Pediatrics, as well as many other organizations, think it is standard of care for pediatric primary care providers to screen, assess, diagnose, and manage-including treatment and referral-adolescent depression,” Zuckerbrot says. “Pediatric primary care providers should feel supported by these guidelines.”
Researchers began investigating this issue in 2007 when the GLAD-PC steering group was unable to reach consensus on a universal adolescent depression screening recommendation, Zuckerbrot says. Instead, the AAP-endorsed GLAD PC guidelines at that time recommended assessment for depression risk factors, with screening advised only for those who were identified with risk factors. Following the 2007 recommendation, work started on updating the guidelines to the current form.
“In these guidelines, we finally endorse universal adolescent depression screening with a formal self-report tool,” she says. “This aligns with the current US Preventive Services Task Force recommendations, as well as the current AAP Bright Futures Preventive Pediatric Health Care table.”
In the 2 GLAD-PC manuscripts, Part I on Practice Preparation, Identification, Assessment, and Initial Management, and Part II on Treatment and Ongoing Management, Zuckerbrot and her Canadian counterpart Amy Cheung, MD, MSc, highlight evidence- and consensus-based methodologies for youths aged 10 to 21 years.1,2 The report reveals that half of teenagers with depression are not diagnosed in the pediatric primary care setting before reaching adulthood, resulting in two-thirds going without needed treatment. Even in cases in which adolescent depression is diagnosed, about half of teenagers still go without appropriate intervention, according to the report. Given the shortage of mental health professionals and the large numbers of adolescents that go either undiagnosed or untreated, the report stresses the need for primary care pediatricians to learn how to identify and manage depression in teenagers.
In addition to the recommendation that all teenagers aged older than 12 years are screened at least once a year for depression, the guidelines also urge pediatricians to identify high-risk patients and educate parents and patients about their options for managing depression in adolescence. Moving into management, the guidelines suggest that pediatricians work with patients and families to develop a treatment plan that is age appropriate and that matches the severity of the patient’s diagnosis. Management plans also should include referrals and/or support with community mental health services, and include a safety plan and emergency management measures for acute episodes and suicidality, according to the researchers.
Suicide is the third-leading cause of death in adolescents, and even when depression doesn’t lead to suicide, it can have lifelong effects on an individual’s health and well-being. According to data from the nonprofit depression and suicide education awareness program I Need a Lighthouse (INAL), roughly 20% of all teenagers experience depression at some point before adulthood, and depression will translate into a substance abuse problem for 30% of those adolescents. Depressed teenagers are also more withdrawn and suffer socially, academically, and in career preparation than their peers, according to INAL.
Pediatricians may have trouble addressing mental health needs in their practice due to the extra staff and time screenings and management require, but the report reveals that many practices have already incorporated mental health into well visits as part of the medical home practice model. Zuckerbrot says she hopes the guidelines will help motivate those practitioners who have yet to take this step.
“We hope that adolescents are better able to access the care that they need to have a happier adolescence. We hope that pediatric primary care providers feel supported in their efforts to deal with behavioral health problems,” she says. “Lastly, we hope that families recognize that their pediatric primary care providers can be a source of help and support for these types of issues, and not just for vaccines and sore throats.”
1. Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D; GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I: Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics. Available at: http://pediatrics.aappublications.org/content/141/3/e20174081.long. Published February 26, 2018. Epub ahead of print.
2. Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein REK; GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II: Treatment and Ongoing Management. Pediatrics. Available at: http://pediatrics.aappublications.org/content/141/3/e20174082.long. Published February 26, 2018. Epub ahead of print.