Mental Health Issues in Adolescents:Screening and Treatment

Lin Sikich, MD

Director, ASPIRE Program

Associate Professor of Psychiatry, UNC

Disclosures for Dr. Sikich

Research support from: NIMH, NIH, NICHD Eli Lilly Janssen Positscience Pfizer Bristol Meyer Squibb

Participation in industry sponsored clinical trials ACTN Neuropharm Bristol Meyer Squibb Curemark Seaside

Meds w/FDA approval in adol depression

Fluoxetine (Prozac) in 8-18 yo’s with MDD Escitalopram (Lexapro) in 12-17yo’s wMDD

All other medications are used off-label for the treatment of adolescent Major Depression

How common is mental illness in youth?

ADHD is about 7% overall, 3% in teens Dysthymia is about 3% in teens Major Depression is 3% in children and ~7%

in teens (equal or sl higher than adults) One in five teens will experience major

depression before they turn 20 Bipolar disorder is ~1%

Prevalence of Pediatric Affective Disorders

Major Depression 1 yr Point Prevalence: children ─ 0.4 - 5 % adolescents ─ 4 - 8% Cumulative Prevalence by age 18: 15-20% Dysthymia, 3 month point prevalence: 0.3% Depression NOS, 3 mth point prevalence: 1.5% Bipolar Disorder 3 month point prevalence: <0.1% Cumulative Prevalence by age 18: 0.4%-1%

Point Prevalence continued

Anxiety disorders are about 10% Schizophrenia is 0.25% - 0.5% Substance Use in past month is 8% in 8th

graders, 16% in 10th and 22% in seniors Alcohol 40%-58%-72% Marijuana 6%-14%- 19%, daily1%-2.7%-5.4% Oxycontin 2%-3.6%-4.7%

Potential Consequences of Depression

↑ risk of physical illness ↑health care costs ↑early pregnancy ↑substance abuse impairments in schooling, social relationships & poorer job outcomes as adults ↑ risk of completed suicide (8%)

Similar risks with other mental illnesses

10% risk of completed suicide with bipolar disorder and with schizophrenia

Substance use increases suicide attempts by 1.4-6.2 OR

Poor health or disability increases suicide attempt by 3.0 OR

Copyright restrictions may apply.Libby, A. M. et al. Arch Gen Psychiatry 2009;66:633-639.

But diagnosis of depression has ’d . . .

Many affected youth are not identified

~50% of those w/depression are not diagnosed Only 25-30% receive any treatment 90% of pediatricians feel they should diagnose but

about ½ feel uncomfortable with their skills or that they don’t have time to fully evaluate

Schools and Primary Care Providers have become main mental health providers

In 2009, USPSTF recommended routine screening for depression in primary care.

Accuracy of Screening tools in teens

Instrument Sensitivity Positive PV Negative PV

PHQ-AD 73 56 97

Beck-PC 91 55.6 98.8

Beck DI >11 84 10 99.5

CES 84 8 99

PHQ-AD free; Beck are proprietary; CES not culturally sensitive, longer with some reverse scoring

PHQ-Adolescent

Rates the past 2 weeks Responses are + not at all +several days

+more than ½ the days +nearly every day MDD if any + response to mood or anhedonia

and total of 5 items >50% of days Other depressive disorder if any + response to

mood or anhedonia and 2-4 items >50% of days Takes ~ 3 min to complete

Also assesses dysthymia, impairment & suicide

Acceptability of screening(Zuckerbrot et al, (2007), Pedatrics 119: 101-108)

3 primary care practices screened 94% of all English speaking adolescents who came for visits while waiting for MD

Provider burden was low Patients were felt to appreciate screening Provider comfort dx’ing depression &

screening for suicidality increased in 80% 73% thought referrals to MHS ↑’d

Screening tools better than interview?

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Depression Depression Suicidality

Self reportInterviewParents

If the screening tool indicates depression, what to do next . . .

Determine severity of symptoms Determine level of impairment Determine if there is suicidality Determine if there is substance abuse R/O other disorders with similar symptoms:

Hypothyroidism Trauma including sexual abuse Bipolar disorder Psychosis

Must ASK directly and specifically about suicide, psychosis, substances and abuse with teen alone

Suicide: Risk by Diagnosis

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Diagnosis of Bipolar Disorder Requires at least 1Manic Episode:

A distinct, qualitatively abnormal period of irritable, expansive or elevated mood AND

3 (4 if irritable) of the following Distractibility Psychomotor Agitation

Pressured Speech Racing Thoughts

Grandiosity Impulsivity

Decreased (< 4-6hrs) Sleep without fatigue

Increased pleasurable and/or productive activities

Mixed Manic & Depressed Episode: Simultaneously meets criteria for both

Not a medication side effect If irritable mood, could easily overlap

agitation, decreased sleep, poor attention Would also need one from each class:

loss of energy, guilt, appetite change, thoughts of death

pressured speech, racing thoughts, grandiosity, excessive negative activities

Should assess for psychotic symptoms if: Mood disorder

In Pediatric Depression 20-40% have hallucinations In youth hospitalized w/mania 80% have hallucinations and 35% have 5 or more psychotic symptoms

Attentional problems don’t respond to stimulants Multiple behavioral problems (school, isolative, aggressive) New onset of unusual or very intense behaviors New onset of social withdrawal Deterioration in level of functioning or distress especially

if strong family history of psychotic disorder Probably in all substance abusers

Early Warning Signs of Psychosis

Increasing withdrawal Reduction in motivation Poor hygiene Feeling picked on Inattention Becoming poorly organized Talking under one’s breath

To assess for psychosis, ask . . . Are there ever times when you hear something and other

people act like they can’t hear it? Or times when you see something and others act like they don’t?

Are there times, when you feel really mad and don’t know why or when you feel everyone is against you?

Parents for times when child has asked if they were called and they weren’t or new onset lying about things

In teens, psychosis is equally likely to occur in affective illness as schizophrenia

Once you have ID’d Depression . . .

Ensure immediate safety: remove guns, hospitalize if needed

Develop strategies to reduce modifiable stressors (eg. school, deadlines)

If mild to moderate depression, psychotherapy alone may be effective

If severe depression, comorbid problems, suicidality or psychosis, likely will need both medication and psychotherapy

Develop a FU plan

Evidence treating Adolescent Depression

TADS Treatment Response

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COMB FLX CBT PBO0

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COMB FLX CBT

Fig. 1: % Responders Fig. 2: No. Needed to Treat

CBT benefit converges in TADS

No benefit of adding CBT to SSRI for initial psychosocial nonresponders

British Primary Care study in 208 adolescents who had not responded to 6 session initial psychotherapy found no advantage of adding CBT

Goodyer et al., 2008. Health Technology Assessment 12 (14).

Partners in Care Study - Asarnow

Randomly assigned 9 peds practices to usual care or quality care

Quality care involved Team leader with depression expertise Care manager who could do CBT Care manager assisted with assessment, referral, both

medication and psychological treatment if family & patient wished

Prior to black box warning on antidepressants

Improving Pediatric Depression Care

(Asarnow et al., 2005 JAMA 293:311-319.)

** ** *

Antidepressant Potential Adverse Effects

TCA’s: sedation, constipation, weight gain sudden cardiac death, lethal in overdose SSRI’s:

Acute side effects often mild (GI distress, dreams) Withdrawal symptoms with short half-life agents Reduced sexual arousal & interest May cause activation May lead to bipolar switch May lead to apathy Suicidality

About 4% of youth treated with antidepressants versus ~ 2% of youth treated with placebo develop significant suicidality..

TADS Suicidality

Concern about suicidality in light of questionable antidepressant efficacy

Number Needed to Treat = 9 Number Needed to Harm = 59Further, there are high rates of emergent suicidality

with psychotherapy too. (Bridge et al., (2005) AJP 162:2173-2175)

10/88 in CBT trial had SI during trial w/1attempt Higher total depression scores More cognitive distortion More likely to have endorsed SI on Beck at w0 40% revealed only by self report, 60% both

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FDA issued black box warning for all antidepressants used in pediatric patients

Does not prohibit use of antidepressants in youth Calls upon physicians and families to closely

monitor child for clinical worsening, unusual behaviors suicidality Especially when treatment starts or dose changes

“Ideally, such observation would include: At least weekly, face-to-face contact during 1st 4 weeks At least biweekly face-to-face weeks 5 through 8 Then at week 12 and subsequently as clinically indicated

AACAP guidelines say monitoring should be individualized based on risk on specific schedule and is a partnership between MD, patient, and family

What if there is substance abuse?

Refer for specific substance abuse treatment

Strongly consider regular home monitoring by parents

Stress increased risk for suicide

What if there is psychosis?

Treat with antipsychotic Refer for specialty mental health care Higher risk of bipolar disorder developing Higher risk of suicide

What if there is bipolar disorder

Refer for specialty mental health care Be very cautious about use of

antidepressant Consider treatment with antipsychotic or ?

Mood Stabilizer

Valproate is not efficacious in ped BP

Placebo n=70; VPA n=74 in DB; Long-term n=54Wagner et al., JAACAP 48:519-532, 2009.

Antipsychotics have efficacy in Pediatric Bipolar Disorder

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Quetiapine Olanzapine Risperidone Aripiprazole

Perc

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Difference

Antipsychotic Associated Weight Gain (Correll et al, JAMA 2009;

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Olanzapine Quetiapine Risperidone Aripiprazole

Molindone Olanzapine Risperidone Mean Acute Wt ↑: 0.3 kg 6.1 kg 3.6kg

Weight change varies within individuals a

Acute and Long-term Weight changes W

eigh

t C

hang

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P <0.008

P <0.0001

P <0.0001

P <0.0001

P <0.0001

Potential strategies for SGA Weight Gain More attention to healthy lifestyle instruction Switch to lower risk agent (aripiprazole/molindone/ziprasidone) Add an adjunctive agent like orlistat, histamine 2 blockers,

amantadine or metformin, which is only agent specifically tested in youth

Klein et al., AJP 2006Klein et al., AJP 2006

Placebo

Metformin

Summary of Studies

Any youth 3-20yrs starting an antipsychotic to monitor for weight & metabolic problems

Youths 10-20yrs who have gained 10% baseline body weight on an antipsychotic to try 3 approaches to reduce weight

Treatment studies for autism and bipolar Developmental monitoring for 3-17yo’s with

autism who do NOT want medication trtmt

How to Refer a Patient to Ask family if you could give their contact information to us

so we can call them with more information about possible studies

Call the ASPIRE Research Hotline at:

Email us at ASPIRE@unc.edu We will provide a comprehensive evaluation We will facilitate care by another provider if we are not able

to accept the child into a study or family chooses not to participate.