Diagnosis and Management of Anxiety and Depression in a Pediatric Setting

Educational Objectives

The goal of this program is to improve the identification and management of anxiety and depression in pediatric patients. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the presenting symptoms of anxiety and depression in pediatric patients.

2. Use screening tools to identify anxiety and depression in pediatric patients.

3. Outline an initial treatment plan for pediatric patients with anxiety and depression.

Summary

Anxiety and depression: according to the Centers for Disease Control and Prevention, suicide was the second leading cause of death in individuals 10 to 34 yr of age in 2017 (data are consistent since at least 2002); anxiety and depression are significant risk factors for suicide; there are few child and adolescent psychiatrists relative to the number of children affected; pediatricians should be prepared to manage mild to moderate disease

Background: anxiety — affects ≈40% of adolescents at some point; of those affected, severe impairment is reported by ≈8%; it tends to be more prevalent in girls than in boys; prevalence is consistent across age groups; depression — of adolescents with depression, the diagnosis is made before adulthood in only ≈50%; ≈66% of affected youth are not identified in the primary care setting; even when diagnosed, only ≈50% receive treatment; Diagnostic and Statistical Manual of Mental Disorders (DSM) — the DSM formerly defined anxiety and depression as synonyms; now, each has its own cluster of diagnoses

Presentation: “central line symptoms” — these include headache, trouble swallowing, shortness of breath, and gastrointestinal issues (mirroring the sympathetic tracts); patients do not typically report “I’m having a lot of worried thoughts,” or “I’m tense and nervous”; consider anxiety and depression in patients with a negative workup for these types of symptoms; children (especially younger patients) with depression often complain of stomachaches; thoughts — anxiety produces worried thoughts about things that might happen (eg, seeing a flower and worrying about a bee sting, seeing a stranger and worrying about being attacked); parents may report that the child does not want to go out, and that they are nervous, tense, and irritable when they do go; depression produces negative thoughts and feelings about oneself or things that happened in the past (eg, “I feel like nobody likes me”, “I’m a failure at school”, “I don’t want to do anything”); behaviors — children with anxiety may become extremely angry and violent over small annoyances; children are using all their mental strength to try to be perfect; they may not have a problem at school, but issues arise when they are home and around someone they feel safe with; children with depression may isolate themselves and give up activities; grades may suffer; distinguish this from normal teenage withdrawal by assessing whether the adolescent is having fun, enjoying things, and engaging with friends

Screening for anxiety: many tools are free of charge; the Pediatric Anxiety Rating Scale (administered by clinicians) and the Screen for Child Related Anxiety Disorders (SCARED; children and parents fill out their own forms) are recommended; SCARED involves 41 questions and differentiates among types of anxiety disorders (eg, generalized, separation, social); it may sync tools with the electronic medical record; consider providing the form before the visit for anyone with mental health issues

Screening for depression: Guidelines for Adolescent Depression in Primary Care (GLAD-PC) — consensus recommendations from the American Psychological Association, American Academy of Child and Adolescent Psychiatry (ACAP), and academic institutions; any child ≥12 yr of age should be screened at least annually; any child with a known history of depression or mood problems, a positive family history, or a history of trauma should be “systematically monitored” (the speaker interprets this as scheduling visits every 2-4 wk); recommended screening tools include the Patient Health Questionnaire 2 (PHQ-2), which bases its questions on the DSM criteria for depression (anhedonia and mood); use the PHQ-9 for patients with ≥2 positive answers (includes questions about the remaining diagnostic criteria, eg, appetite, suicidality), but note that the PHQ-9 is inadequate for suicide screening

Suicidality: consider the Columbia Suicide Severity Rating Scale (CSSRS) for any patient with a mental health issue (assesses the seriousness of suicidality); a yellow rating indicates that the clinician may decide whether to send the child to the emergency department (ED); children with an orange or red score are automatically sent to the ED (these children have thought about how they might commit suicide, which dramatically increases the risk of following through); if the child cannot go to the ED, call the crisis team to come and assess the safety of the child and provide resources for treatment

GLAD-PC recommendations (continued): if the results of screening are positive, conduct an interview based on DSM criteria (eg, irritability, sleep, weight problems); ask about the severity of the issues and how they affect the youth; assess children and their parents; try to discuss mental health issues alone with adolescents; consider speaking with parents alone; patients may not be honest when their parents are in the room

Cognitive behavioral therapy (CBT): first-line treatment for anxiety and depression; supported by good evidence; “cognitive triad” — thoughts, behaviors, and mood influence one another; a patient with depression has depressed thoughts causing them to see the negative aspects of anything that happens; CBT helps people identify negative thoughts and explore what might actually be happening; course of CBT — typically 10 to 12 wk; excellent efficacy

Selectives erotonin reuptake inhibitors (SSRIs) for anxiety: effective for generalized anxiety, social phobia, and separation anxiety disorder; fluvoxamine, fluoxetine, and sertraline are well studied; no SSRI is superior to another; ask about a family history of successful treatment for anxiety, and start with that medication (to take advantage of any genetic predisposition to efficacy)

GLAD-PC recommendations for treatment of depression: mild depression — try supportive treatment (eg, extra visits, school counseling); moderate depression — assess the severity of the impact on life; if the child’s grades and activities are acceptable, consider referral for counseling rather than starting medication; severe depression — start treatment with therapy and medication; clinician consultation with a mental health specialist is recommended at every step of the GLAD-PC algorithm; starting medication — allow 6 to 8 wk to assess efficacy; if symptoms have mostly resolved, continue treatment ≥1 yr; if there is no improvement, increase the dose of medication until a response is observed or the maximum dose is reached (may take several weeks); remind families to be patient and that finding the correct medication requires trial and error; see patients more frequently during this process and ask for advice if needed; further recommendations — refer to and consult with a psychiatrist or counselor; use treatments (eg, SSRIs, CBT) that are supported by science; there is no evidence for the efficacy of cannabidiol (CBD), although it does not worsen psychiatric issues; there is no evidence for the efficacy of marijuana; the ACAP prohibits providing marijuana to adolescents because of its significant deleterious effect on the development of white matter (lowers IQ permanently, increases risk for mood disorders later in life); monitor for adverse events

Adverse effects of SSRIs: nausea and headache are most common (typically lasting ≈1 wk); black box warning — SSRIs may increase suicidal behaviors and thoughts in adolescents; in the early 2000s, clinicians in the UK noticed an increase in suicidal ideation in teenagers taking paroxetine (Brisdelle, Paxil, Pexeva), with a possible increase in suicide attempts and behaviors; the UK banned the use of paroxetine in teenagers, triggering the US to assess all SSRIs; meta-analysis found an increase in suicidal thoughts in children taking SSRIs compared with those taking placebo (4% vs 2%; statistically significant); notify families and discuss this risk with children; also note that, of the many tens of thousands of children included in the analysis, none completed suicide; paroxetine — has the highest rate of adverse effects (eg, diarrhea, cramping); study doses — because most drug studies last 8 to 12 wk, companies often start at a dose that would take weeks to reach in actual practice; providing a depressed patient with a drug at a dose that causes uncomfortable adverse effects pushes them to use their existing coping skills (suicidality, cutting); communication — have a dialog with families when starting SSRIs; advise teenagers to communicate when parents ask about the medication; monitor patients; effects of the black box warning — prescriptions for SSRIs decreased, and the rate of suicide increased in the US and UK

Use of SSRIs in practice: the precise degree of efficacy is unknown; some youth need to try 2 or 3 medications; reassure patients they will not take the medication forever

Readings

Adegbite-Adeniyi C et al: An update on antidepressant use and suicidality in adolescent depression. Expert Opin Pharmacother 2012 Oct;13(15):2119-30; Birmaher B et al: Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 2007 Nov;46(11):1503-26; Cheung AH et al; GLAD-PC Steering Group: Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics 2018 Mar;141(3): e20174082. doi: 10.1542/peds.2017-4082; Cipriani A et al: Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. Lancet 2016 Aug 27;388(10047):881-90; Connolly SD and Bernstein GA; Work Group on Quality Issues: Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 2007 Feb;46(2):267-83; Cooper WO et al: Antidepressants and suicide attempts in children. Pediatrics 2014 Feb;133(2):204-10; Posner K et al: The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry 2011 Dec;168(12):1266-77; Richardson LP et al: Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics 2010 May;125(5): e1097-103. doi: 10.1542/peds.2009-2712; Zuckerbrot RA et al; GLAD-PC Steering Group: Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics 2018 Mar;141(3): e20174081. doi: 10.1542/peds.2017-4081.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Zaharopoulos was recorded at the 43rd Annual Melvin L. Cohen, MD, Pediatric Update 2020, presented by Phoenix Children’s Hospital, and held March 9-12, 2020, in Scottsdale, AZ. For information about upcoming CME conferences from Phoenix Hospital, please visit www.phoenixchildrens.org. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD664001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.