4/7/2021 Considering and Starting Treatment for Depression & Anxiety Abigail Schlesinger MD 1 Goals and Objectives At the completion of this program, participants should be able to: 1. Recognize the importance of the behavioral health differential diagnosis when prescribing medication for depression/anxiety 2. Describe a method to deploy components of their behavioral health toolbox(therapy strategy, safety plan, and/or medication) 3. Recognize the importance of appropriate follow-up for behavioral health interventions provided in pediatric primary care 2 2 1 4/7/2021 Therapeutic Toolbox Follow-up Non-medication Interventions Safety Planning Medication Referral and Coordination 3 3 Nonmedication Interventions Relationship HELLPP Skills Assessment Health Behavior Interventions BH Interventions 4 4 2 4/7/2021 Organizing the Session Set Agenda Recognize frustration/fears/anger/strengths & instill hope Clarify Needs(assessment, differential, safety planning) • Listen and Ask targeted questions sleep, appetite, routines, school, friends, mood, hope/helplessness Create clear plans • I understand you are here for depression. Today I am going to ask questions and listen to you so that I can better understand your concerns.Then we will come up with initial goals/strategies to improve your mood 5 5 GAD-7 6 6 3 4/7/2021 PHQ-9 7 7 Depression: Assessment with SIG-E-CAPS Depressed and/or irritable mood PLUS…. Sleep problem(up or down) Interest deficit (anhedonia) Guilt (worthlessness, hopelessness, regret) Energy deficit Concentration deficit Appetite changes(up or down) Psychomotor agitation or retardation Suicidality 8 8 4 4/7/2021 DSM 5 Criteria: Major Depressive Disorder 1. Sad, down, negative mood, Irritable, easily frustrated, empty feeling, hopelessness, argumentative. Focused irritability in children on negative events, interprets events as 2. Anhedonia, decreased interest or loss of pleasure negative, discounts positives. “I don’t care” 3. Changes in sleep attitude 4. Changes in appetite Not enjoying or quitting activities; Subjective report or observed by others May sleep/eat more or less. 9 9 DSM 5 Criteria: Major Depressive Disorder 5. Decreased concentration, Easily swayed by others, decisiveness changes mind, may question if developed 6. Psychomotor agitation or ADHD, amotivation retardation, observable by others Complaints of feeling agitated, noted pacing/ increased negative energy, or “couch potato”, amotivation 10 10 5 4/7/2021 DSM 5 Criteria: Major Depressive Disorder 7. Complaints of fatigue or Regardless of increased or decreased sleep decreased energy Negative about self, low self esteem, may feel 8. Feelings of responsible for events out of worthlessness or their control, discount positives and focus on excessive/inappropriate negatives guilt May think family would be better off without them for 9. Death wish, suicidal fleeting moments or chronically think life isn’t ideation worth it, want to hurt self but no plan, or have a plan, and/or intent 11 11 DSM 5 Anxiety Disorders • Generalized Anxiety Disorder • Social Anxiety Disorder • Separation Anxiety Disorder • Selective Mutism • Specific Phobia o Animal, natural environment, blood-injection-injury, situational, other • Panic Disorder • VS Panic as a part of depression • Other Specified Anxiety Disorder • Also consider: Somatoform Disorder, OCD 12 12 6 4/7/2021 Anxiety: Developmental Issues Preschool=predominantly separation School age=worries decrease for separation and focus on performance Adolescents=worries of peer acceptance 13 13 DSM 5 Criteria: Generalized Anxiety Disorder Diagnostic Criteria Clinical Pearls • Essential feature is • These kids can worry excessive worry about the fact that they (apprehensive worry. expectation, fear of the • If they’ve had it their future) more days than whole life they might not not for at least 6 months see it as a problem, • Worries are difficult to even though their entire control family alters their life to help 14 14 7 4/7/2021 DSM 5 Criteria: Generalized Anxiety Disorder Diagnostic Criteria Clinical Pearls • In children, must have one of • Be alert for this diagnosis the following: when a child and/or o c/o restlessness family is concerned o easily fatigued about ADHD but the teacher reports only o difficulty concentrating minimal inattentive o irritability symptoms. o muscle tension • Teachers often love o sleep disturbance these kids. 15 15 GAD: Assessment Most common anxiety disorder diagnosis Screening questions Would you describe yourself as a worrier? Ask the kid or parents about bedtime. “What if” questions Give examples of common worries—the weather, robbers, grades, terrorism, health concerns. Ask teens if they worry about their future 16 16 8 4/7/2021 DSM 5 Criteria: Social Anxiety Disorder Diagnostic Criteria Clinical Pearls • Anxiety caused by • May take a bad grade exposure to a feared or skip school in order to social situation o Exposed to scrutiny avoid situation. o Must include peer settings o Fear of embarrassment/rejection by peers • Doesn’t mean that they • Attempt to avoid social are not social…they situations or endure at must have some age great distress appropriate friendships. o Children may cry, tantrum, freeze, or shrink from the exposure • Will overuse • Symptoms present for at texting/internet for least 6 months communication 17 17 SAD: Assessment • Would you describe yourself as shy? • When you are around your peers, do you worry about saying the wrong thing? Getting embarrassed? • Will you raise your hand in class? • Will you order food at a restaurant? 18 18 9 4/7/2021 DSM 5 Criteria: Separation Anxiety Disorder 3+ of the following symptoms are present: Distress with separation or anticipated separation Worry about losing caregiver or harm coming to them Illness, injury, disasters, death Worry of untoward event causing separation lost, kidnapped, illness Physical complaints w/ separation or anticipated separation Headaches, stomachaches. Sunday nights. Persistent reluctance to leave home because of fear of separation Persistent reluctance to sleep away from home or sleep without having caregiver near 19 Repeated nightmares of separation 19 DSM 5 Criteria: Separation Anxiety Disorder Onset from preschool until 18 years of age Duration at least 4 weeks Developmentally inappropriate worry related to separation from home or to whom one is attached 20 20 10 4/7/2021 Separation Anxiety Disorder: Assessment • Question parents but sometimes children may have insight. • Ask about difficulties separating in general. Start with younger years— preschool, school age. • Ask how they did in preschool/kindergarten separating from parents • Where do they sleep? Do they sleep alone? • Will they go on overnights/sleepovers? • History of separation anxiety increases risk of other anxiety disorders. 21 21 DSM 5 Criteria: Panic Disorder Recurrent, unexpected panic Dizzy, Derealization attacks Chills or unsteady, depersonalization flushed light- Panic attack: an abrupt surge of headed intense fear that reaches peak within minutes 4+ symptoms Sweating Chest Choking Palpitations, fast pain HR Attacks followed by 1+ months: Fear of losing Persistent concern/worry about Shaking GI distress Fear of control/”going more panic or their dying crazy” consequences Significant, maladaptive change in behaviors SOB, suffocating Paresthesias 22 22 11 4/7/2021 Panic Disorder: Assessment • Have you ever had a panic attack? o Describe it. • Have you ever had anxiety so extreme that you noticed symptoms in your body? • How long did it last? • Are there precipitants? • Are you avoiding certain things out of fear of having another panic attack? • Panic disorder vs. panic attack specifier. 23 23 SCAReD Scoring 24 24 12 4/7/2021 25 25 26 26 13 4/7/2021 Initiation Check(s) 1.Validate Diagnosis & Safety 2.Review Family History 3.Complete Consent/Assent 4.Clarify Goals/Expectations/Safety Plan 5.Start Medication 6.Schedule follow-up 27 27 1. Validate Diagnosis & Safety Review work-up - medical diagnosis & comorbid psychiatric ASSURE SAFETY Confirm Diagnosis Review Behavioral Scales SCARED parent and child(7-18) or GAD-7(13 and over 18) PHQ9(or PHQ9a) Consider Comorbidities that can Complicate Treatment 28 28 14 4/7/2021 Consider Psychiatric Comorbidities that Could Complicate Treatment Bipolar Disorder Assess personal history Autistic Spectrum Are ASD driving “anxiety behaviors” Disorder Trauma Acute or Chronic Trauma Substance Use Consider Substance Screen Eating Disorder Medication won’t work if you don’t have enough food to feed the brain Suicidality Assess past and Current ADHD & ODD Consider Vanderbilts 29 29 Screening for Bipolar Disorder “Was there ever a period of time, for more than a few days, that you(or your child) didn’t need sleep, was on top of the world, and significantly different than usual” Note This should be a clear change from baseline. Child should be energetic during the day, ie not need a nap, not go to bed early There is the most concern for bipolar disorder if the child was euphoric(more happy than normal) or grandiose(felt that they were special, had special powers etc) and there is no reason for it(ie it’s not the day before a holiday) 30 30 15 4/7/2021 Safety Safety should be assessed in all children and adolescents 31 31 Depression & Suicide Untreated depression is the number one cause of suicide Over 90% of children and teens who complete suicide have a mental health diagnosis (Mental Health: A Report of the Surgeon General)