Pediatric Depression and Suicide: An Update for School Nurses

W. Burleson Daviss, MDDept. 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:

Sleep problems Interests decreased Guilty, worthlessness Energy problems Concentration problems Appetite problems Psychomotor activity problems: agitation or

slowing Suicidal 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:

Grandiosity Racing thoughts Reckless pleasure-seeking behavior Activity increased (goal-directed) Pressured speech Insomnia: decreased need for sleep Distractibility

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

CAUSE # OF DEATHSAccidents 6646Homicide 1899Suicide 1611Cancer 732Heart Disease 347Congenital Anomalies 255Chronic Lower

Respiratory Disease 74Stroke 68Influenza and Pneumonia 66Blood Poisoning 57

Anderson & Smith 2003

1599

C.E14

Suicide: 3rd Leading Cause of Death in Youths Ages 15-19— U N I T E D S T A T E S, 2001 —

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 OptionsPsychosocialPharmacological

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)

30

40

50

60

Baseline Week 6 Week 12

Stage I Assessments

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TADS Team (2004), JAMA 292: 807-820

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

DepresseDepresseddChild or Child or Teen?Teen?

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

• Feelings of worthlessness

• Feelings of hopelessness

•Sleep Problems

Those who qualify will receive: Interview and Assessment Physical Exams Comprehensive Lab Analysis Medication Resource ReferralCompensation availableContinued care if applicableCall 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

C.E16.XX

Why Use Antidepressants At All? US Epidemiological Studies, Ages 15-24

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Anderson 2002, CDC Wonder 2003, USDHEW 1956, Vital Statistics U.S. 1954–1978

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Females

Males

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