Describe the collaborative care model for the management of depression.

Determine safety and efficacy of using antidepressant therapy for depression after stroke and depression in pregnancy.

Discuss diagnostic features, prevalence, and comorbidities of other anxiety disorders.

Select safe and effective treatment of depression in children.

Counsel children and adolescents about suicide and anxiety disorders.

Primary Care Management of Adult Depression and Anxiety

Symptoms of depression: sleep disturbance; change in interest level; guilty feelings; energy reduction; concentration reduction; appetite changes; psychomotor symptoms (eg, retardation, agitation); suicidal thoughts; patients must have ≥5 symptoms (one symptom must be depressed mood or anhedonia [loss of pleasure])

Categories of depression: major depressive disorder (MDD); dysthymic disorder (low-grade depression; lasts ≥2 yr); adjustment disorder (associated with specific stressor; lasts ≤6 mo); mood disorder due to general medical condition; substance-induced mood disorder; bereavement

Epidemiology: common; lifetime rate, 17%; current rate in US adults, 2% to 4%; more common (2:1) in women than in men; not related to ethnicity, education, or socioeconomic or marital status; 1.5 to 3.0 times more common in first-degree relatives; average age at onset, 20 to 30 yr; patients with history of one episode of MDD have ≤60% chance for second episode (after 2 episodes, 70% chance for third episode; after ≥3 episodes, 90% chance for subsequent episode); rates of MDD differ between practice settings (eg, rates higher in inpatient settings compared to outpatient settings)

Atypical antipsychotic agents and bipolar disorder: 5% to 10% of time, unipolar depression progresses to bipolar depression (bipolar III disorder; medication-induced mania); rare

Comorbidities: current MDD, past MDD, and severe medical illness associated with increased mortality; other health risks and behaviors (eg, tobacco smoking, alcohol abuse, obesity)

Listening to patients: physician’s perspective—valuable; may be difficult due to time constraints; fear of “Pandora’s Box” (eg, “I can’t address that because the person will fall apart or be in my office for a long time”); patient’s perspective— physicians listen less now; patients seek out providers who listen; study concluded that treatment of depression must include listening, screening, medications, and referral; findings of study of 15 patients with depression in past year—most primary care providers did not ask about depression and did not use past depression as cue to screen for current depression; most patients received limited information and treatment options; patients lacked motivation to seek information independently; limited collaboration between physicians and patients on treatment decisions

Screening: United States Preventive Services Task Force (USPSTF) recommends screening for adults and competent follow-up; “your choice” to screen children and adolescents; meta-analysis found single-item screening questionnaire as effective as others (sensitivity ≥80%)

Collaborative care model: based on concept of chronic disease management; group practices placed in collaborative care conditions; primary care provider initiates referral for depression; case manager (trained midlevel provider) follows patients (eg, places telephone calls, assesses depression and medication adherence); mental health professional provides weekly supervision; requires education (eg, 1-2 hr of continuing medical education) at beginning of project, and every 3 to 6 mo thereafter; benefits—patients more likely to begin, adhere to, and complete treatment; higher measures of life satisfaction and function; patients more likely to be working after 12 mo; physicians more likely to conclude that depression can be managed in primary care settings (“getting around Pandora’s Box”); depression more likely to resolve or improve, compared to usual care (40%-50% vs 25%-40%); comorbid depression with chronic physical conditions can be successfully managed; improved quality of depression care; cost-neutral if not cost-effective

Depression after stroke: occurs in ≈20% of hospitalized patients and 20% to 25% of ambulatory patients; functional rehabilitation and cognitive function poor; increases 1-yr and 10-yr mortality; antidepressants—improve depression, cognitive function, and general function; 2 in 3 randomized controlled trials show reduced likelihood of subsequent stroke and death within 6 to 24 mo

Depression and myocardial infarction (MI): depression increases risk for first MI; uncertain whether treatment of depression prevents first MI; depression after MI increases likelihood of subsequent MI and death; safe to treat depression with selective serotonin reuptake inhibitors (SSRIs), but uncertain whether effects similar to those of treating patients with stroke; some studies found use of antidepressant in tobacco smokers with depression after MI reduced recurrence of MI

Treatment of depression in pregnancy: older studies do not support connection between tricyclic antidepressants (TCAs) and birth defects; newer studies suggest increased risk (eg, lower birth weight, preterm birth, fetal death, seizures, discontinuation syndrome) to infants with some SSRIs (particularly agents with shorter half-lives); paroxetine (Paxil; category D); fluoxetine (eg, Prozac) typically recommended (“if you’re going to use something, that’s probably the safest”); problem rates low; study designs do not allow inference of causality (most studies retrospective cohort studies); similar adverse outcome rates associated with untreated depression during pregnancy; history of depression major risk factor for relapse (relapse rate in pregnancy, 43%-66% [depending on continuation of medication]); lactation—maternal serum levels of antidepressant drugs low; some studies suggest maternal depression can adversely affect child development; recommend taking medications at night (breast-feeding during day, and bottle-feeding at night)

Panic disorder: features—recurrent or unexpected panic attacks; ≥1 mo of worry about having another attack; behavioral changes (eg, avoidance); prevalence—lifetime rate, 1% to 2% (10%-30% in medical settings); comorbidities— depression; other anxiety disorders; treatment—SSRIs and TCAs equally effective; cognitive behavioral therapy (CBT) and medications equally effective; unclear whether combining psychotherapy with medications (“clinical rule of thumb”) more effective

Social phobia: features—intense persistent fear and immediate anxiety associated with social or performance situations; person recognizes response irrational, but “just can’t seem to help [him or her]self”; avoidance of situations or facing situations with dread; prevalence—lifetime rate, ≤13%; 85% of patients experience academic or occupational difficulties; comorbidities—depression; other anxiety disorders; substance abuse; treatment—SSRIs; monoamine oxidase inhibitors (MAOIs); benzodiazepines; β-blockers for performance anxiety; 75% improvement with CBT (fewer relapses than with medication); uncertain whether combination treatment more effective than medication or CBT alone

Obsessive-compulsive disorder (OCD): features—recurrent obsessions or compulsions; severity causes marked distress; obsessive behavior for >1 hr/day; person recognizes behavior as unreasonable or excessive but “can’t help yourself”; onset in boys and men, 13 yr of age to young adulthood (in women, 20-30 yr of age); long-term course of waxing and waning; prevalence—lifetime rate in community samples, ≤50%; comorbidities—depression; anxiety; tics; Tourette’s syndrome; treatment—SSRIs (higher doses than those used to treat depression); 8 to 12 wk for complete response; uncertain whether combined therapy more effective; speaker prefers using combined therapy (discuss with patient)

Posttraumatic stress disorder (PTSD): features—traumatic life event; ≥1 re-experiencing symptom (eg, flashback, nightmare); avoidance and emotional numbing; physiologic arousal (eg, jumpiness, anxiety, insomnia); prevalence—lifetime rate, 8%; in primary care samples, 10% to 20%; current lifetime rates, ≤33% (condition may be underidentified); comorbidities— depression and other anxiety disorders; health risk behaviors (eg, tobacco smoking, alcohol abuse, obesity); treatment— SSRIs; other antidepressants; benzodiazepines; mood stabilizers; atypical antipsychotic agents; eye movement desensitization

Questions and answers: β-blockers—useful for patients with performance anxiety, but not particularly useful for patients with PTSD; PTSD—after traumatic life event, stress debriefing (discussing and processing event) does not appear to prevent development of PTSD; use of medications (eg, β-blockers, SSRIs) reasonable, but “has not panned out in terms of research”; lifetime rate of depression—17% in community samples (doubled in ambulatory settings); suicidality—95% of people who commit suicide have mental health issue; risks include personal family history of suicide attempts, genetics, precipitating events (eg, loss of job), and lethality of means

Primary Care Management of Pediatric Depression and Anxiety

Management characteristics of family physician: strong sense of responsibility; ability to assist patients in coping with everyday problems and in maintaining stability in family and community

Normal fears and developmental issues: infants—loud noises; easy startling; anxiety around strangers; toddlers— imaginary creatures (eg, boogeyman); fear of dark; separation anxiety; school-aged children—worry about injuries; fear of natural events (eg, thunderstorms); older children and teenagers—anxiety about school performance; social competence (eg, appearance); health issues (eg, awareness of self and development)

Screening recommendations: USPSTF suggests insufficient evidence about whether issues (eg, substance use, depression, suicide, contraception) should be discussed with children, teenagers, and young adults; other agencies (eg, American Academy of Family Physicians [AAFP]) suggest reasonable to screen for issues at appropriate times

Cognitive development: abstract thinking and understanding of cause and effect (eg, consequences of tobacco smoking) develops in adolescence; ability for abstract thinking and number of risky behaviors increases in late adolescence

Assessment: American Medical Association’s Guidelines for Adolescent Preventive Services (GAPS) questionnaire— multiple forms available (eg, adolescent-directed, parent-focused; English or Spanish); covers medical history, family information, related health issues, and health profile (eg, eating, violence, tobacco use); asks about concerns; caring for adolescents—offer chance to be examined and counseled separately from parent or guardian; make reasonable effort to encourage adolescent to involve parents and guardians in health care decisions; educate parents to encourage adolescents to take personal responsibility in health care; facilitate communication about appointments and payments; discuss and maintain confidentiality

Childhood depression: criteria—according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV); ≥5 symptoms occur during 2-wk period; decline from previous functioning; depressed mood or loss of interest or pleasure; consider child’s ability to articulate symptoms; symptoms—depressed mood; irritability; diminished interest or pleasure; boredom; weight loss or gain; insomnia or hypersomnia; agitation or retardation; fatigue; worthlessness; guilt; attention or concentration difficulties; thoughts of death; stomachaches; headaches; consider functional impairments (eg, relationships with peers); rule out substance abuse, bereavement, and bipolar disorder

Risk factors: chronic illness; female sex (2:1); hormonal changes; positive family history; serotonin transporter gene (long/ short or short/short genotypes); childhood neglect or abuse; stressors (eg, moving); loss of loved one, parent, or romantic relationship; anxiety disorder; attention-deficit/hyperactivity disorder (ADHD); conduct or learning disorders; alcohol or drug abuse; tobacco smoking; history of depression

Comorbidities: anxiety disorders; disruptive behavior disorders; substance abuse; 1 in 5 may develop bipolar disorder; adolescents with bipolar disorder—ADHD; conduct disorder; anxiety disorder

Psychotherapy: CBT effective for mild to moderate childhood depression; physician-based counseling—education about healthy coping skills, problem solving, conflict resolution, social and assertiveness skills, and relaxation techniques; educate parents about realistic age-appropriate expectations and appropriate communication strategies; support healthy behaviors, psychologic defenses, and relationships; listen to teenagers (as “an ally”)

Medications: TCAs ineffective for depression and anxiety in children (limited effectiveness in adolescents); SSRIs have strongest (but still somewhat limited) evidence for effectiveness (highest efficacy in patients ≥13 yr of age); studies using SSRIs often flawed (eg, high placebo response rates, and no statistical power to evaluate suicidality); meta-analysis—looked at pediatric trials using antidepressants to treat depression, OCD, or other anxiety disorders; medications included SSRIs, nefazodone, venlafaxine (Effexor), and mirtazapine (Remeron); outcomes of interest included response status, reduction in depression scores, and suicidal ideations and attempts; number needed to treat (NNT) for MDD, 10 (NNT for OCD, 6; NNT for other anxiety disorders, 3); compared to other treatments, “this is as good as it gets for efficacy”; SSRIs and newer antidepressants effective in teenagers; number needed to harm, 143; fluoxetine preferred choice for children <13 yr of age; carefully weigh risks and benefits; weekly follow-up recommended for first month of antidepressant use (every other week for second month; assess for subsequent follow-up); length of treatment—for first episode of depression, 6 mo of treatment; ≥12 mo for second episode; 1 to 3 yr for third episode

Suicidality: extremely rare before puberty; third leading cause of death in persons 10- to 24-yr of age; risk factors—mental health disorder; precipitating event; previous attempts predict subsequent attempts; positive family history of attempt; boys more likely to successfully commit suicide; identity issues (eg, sexuality); hopelessness; suicide prevention—physician education about recognition and treatment of depression; restriction of lethal means (eg, weapons, medications); ask about suicidality and mood; be direct, reassuring, and nonjudgmental; reduce stress; mitigate risk factors; treat depression or other mental health problem (including substance abuse); consider hospitalization or crisis stabilization services; do not prescribe potentially lethal medications; do not let fear of bad outcome impair ability to assess and treat patients

Generalized anxiety disorder: features—excessive worry; other issues (eg, fatigue, muscle tension, sleep disturbance) occur chronically (≥6 mo); affects 3% to 5% of adolescents; comorbidities include other mental health disorders; treatment— CBT; SSRIs may be helpful; frequent visits for reassurance

Social phobia: features—marked and persistent fear of ≥1 social or performance situations; children do not recognize response as unreasonable; shyness may precede social phobia; comorbidities include other mental health disorders and substance abuse; treatment— β-blockers for performance-based issues

Obsessive-compulsive disorder: onset for boys typically earlier than in girls; 50% of adolescents with OCD have other anxiety disorders (eg, depression, tics)

Posttraumatic stress disorder: traumatic event related to fear, helplessness, or horror; re-experiencing symptoms; avoidance and emotional numbing; patients jumpy and easily startled; functional impairment; symptoms last >30 days

Questions and answers: confidentiality—can be breached if patient poses danger to self or others; talk with patients to assess abstract thinking ability, coping ability, or stability of home situation; behavior therapy—assign positive activities (eg, exercise); prescribing antidepressant alone incomplete management of depression