Pediatric Depression and Suicide

Question 1

Risk factors for depression

6

Answer 1

1. Personal or family history of depression
2. Personal or family history of Bipolar disorder
3. Suicide related behavior
4. Substance abuse
5. Other psychiatric illnesses
6. Significant psychosocial stressors (family crisis, abuse, neglect, trauma)

Question 2

Screen for depression if symptoms warrant it and yearly

1. Screening tools? 4
2. Personal interview? 1

Answer 2

1. Screening tools
   - GAPS (Guidelines for Adolescent Preventive Services)
   - Beck Depression Inventory
   - Kutcher Adolescent Depression Scale
   - SDQ (Strengths and difficulties questionnaire)
2. Personal interview
   HEADSS

Question 3

HEADSS based interview questions

Answer 3

H (home)

E (education, employment)

A (activities)

D (drugs)

S (sexuality)

S (suicide/depression)

Question 4

Criteria for diagnosis of depression
(DSM-IV-TR and DSM 5)

Absolute requirements? 2

Needs to include how many of the following symtpoms and what are they?
9

Symptoms cannot be due to what? 3

Answer 4

1. A major depressive episode in children and adolescents typically includes at least 5 of the following symptoms during the same 2-week period
2. At least one of the symptoms needs to be depressed mood or loss of interest or pleasure
3. Depressed (or irritable) mood
4. Diminished interest or loss of pleasure in almost all activities
5. Sleep disturbance
6. Weight change, appetite disturbance, or failure to achieve expected weight gain
7. Decreased concentration or indecisiveness
8. Suicidal ideation or thoughts of death
9. Psychomotor agitation or retardation
   8 . Fatigue or loss of energy
10. Feelings of worthlessness or inappropriate guilt
11. Symptoms are not due to a medical condition or other psychiatric disorder (bipolar)
12. Symptoms are not due to the direct physiological effects of a substance
13. Symptoms are not better accounted for by bereavement beyond 2 months

Question 5

Depressive symptoms in children and pre-pubertal youth

5

Answer 5

1. Somatic complaints
2. Psychomotor agitation
3. Mood-congruent hallucinations
4. School refusal
5. Phobias/separation anxiety/increase in worrying

Question 6

Depressive symptoms in adolescents and post-pubertal youth

6

Answer 6

1. Low self esteem, apathy, boredom
2. Substance use
3. Change in weight, sleep or grades
4. Psychomotor depression/hypersomnia
5. Aggression/antisocial behavior
6. Social withdrawal

Question 7

Discuss the difference between depressive symptoms in younger children and in teens?

Answer 7

Younger children may present with more somatic symptoms and more likely to have psychomotor agitation

Teens may be more likely to present with social withdrawal, substance use and psychomotor depression

Question 8

Signs and symptoms of major depression

SIGECAPS

Answer 8

S Sleep disturbance

I Interests (decreased for usual activities)

G Guilt (excessive or inappropriate)

E Energy (decreased)

C Concentration problems

A Appetite change

P Pleasure (decreased)

S Suicidal thoughts or actions

Question 9

What is the goal of interviewing the caregivers of the pediatric depression pt as well?

Answer 9

Goal is to establish how much support the patient has and to assess for safety (suicidal behaviors)

Question 10

Medical evaluation to rule out other etiologies

6

Answer 10

1. Infection (Mononucleosis)
2. Medication side effects
3. Endocrine disorder (Thyroid disorder)
4. Tumor
5. Neurologic disorder
6. Miscellaneous (anemia)

Question 11

Differential diagnosis

9

Answer 11

1. Normal moodiness of teens
2. Major depressive disorder
3. Substance induced mood disorder
4. Adjustment disorder
5. Anxiety disorder
6. PTSD
7. Bipolar disorder
8. Eating disorder
9. Conduct disorder

Question 12

Suicidal behaviors in children and teens include:

9

Answer 12

1. Expressing self destructive thoughts
2. Drawing morbid or death-related pictures
3. Using death as a theme during play in young children
4. Listening to music that centers around death
5. Playing video games that have a self-destructive theme
6. Reading books or other publications that focus on death
7. Watching TV programs that center around death
8. Visiting internet sites that contain death related content
9. Giving away possessions

Question 13

Teens at high risk for suicide

2

Answer 13

1. SAD PERSONS

2. + Family history of a first degree relative who committed suicide *

Question 14

What does SAD PERSONS mean?

which ones are the critical high features 5

Answer 14

S (sex) females attempt more, males* complete more

A (age) over 16*

D (depression) and comorbid conduct disorder/impulsive/aggression/anxiety

P (previous attempts)*

E (ETOH) or other substance abuse (SA)

R (rational thinking lost) psychotic or SA

S (social supports lacking)*

O (organized plan) **

N (no significant other)

S (sickness or stressors)

Question 15

Treatment for depression

4

Answer 15

1. Initial management of depression includes patient and caregiver education
2. Develop a treatment plan with patient and family
3. Establish relevant links with mental health resources in the community
4. Safety plan

Question 16

Step 1: Initial management

3

Answer 16

1. Educate that depression is often recurrent and what treatment options are available
2. Parental reaction may include sadness, anger or denial
3. Confidentially – make it clear that the content of the visits are confidential unless there is evidence of imminent harm to self or others

Question 17

Step 2: Develop treatment plan

2

Answer 17

1. Set specific treatment goals in key areas of functioning
   - Home, peer and school settings
   - Written goals (exercise, self care, homework, etc.)
2. Determine treatment plan based on severity of symptoms

Question 18

What are some options for pedatric depression treatment? 3

Answer 18

Determine treatment plan based on severity of symptoms

1. Cognitive behavioral therapy,
2. interpersonal psychotherapy,
3. SSRIs

Question 19

Step 3: Community resources

What does this step include?

Answer 19

Refer to appropriate support groups which may be available in the community

Question 20

Step 4: Safety plan

What does this include?

Answer 20

All management must include a safety plan

This is a specific set of instructions for the patient to help recognize their symptoms and what they will do if they feel unsafe

Question 21

Mild depressive symptoms
Treatment plan?
6

Answer 21

1. May choose active monitoring for a short time
2. Frequent visits
3. Prescribe regular exercise or leisure activities
4. Recommend peer support group
5. Review self management goals
6. Provide education

Question 22

1. Cognitive behavior therapy is based on what?

2. Goal of treatment?

Answer 22

1. Based on the principle that one’s thoughts, feelings and behaviors affect one another.
2. Goal of treatment is to modify the negative thoughts and behaviors.

Question 23

1. Interpersonal Psychotherapy is based on what?

2. Goal of treatment?

Answer 23

1. Based on the principle that depression occurs in an interpersonal context
2. Goal of treatment is to address the interpersonal problems that may be contributing to or resulting from the depression

Question 24

Can start by depression therapy management discussing what things with the patient?
5

Answer 24

1. Assessing prior treatment success
2. Family history of successful antidepressant use
3. Discussion of duration of treatment (6 mo to 1 year after cessation of symptoms)
4. Reviewing safety data of medication
5. Reviewing side effects

Question 25

Medical treatment with SSRIs (selective serotonin reuptake inhibitors) 2 (state the ages that each med is approved for)

Answer 25

1. Fluoxetine (Prozac) (FDA approved ages 8 and up for depression and OCD) 2. Escitalopram (Lexapro) (FDA approved ages 12 and up for depression)

Question 26

Whats reccommended for the first SSRI?

Answer 26

Fluoxetine (Prozac)

Question 27

Fluoxetine (Prozac) 1. Dose? 2. Taper how? 3. Effective dose at what? 4. Max dose?

Answer 27

1. 10mg once daily 2. Taper up by 10 mg increments every 1-2 weeks Example: Take ½ of a 20mg tab for 2 weeks then increase to a whole tab 3. Effective dose 20 mg 4. Max dose 60 mg

Question 28

Prozac the pro’s | 2

Answer 28

1. Long half life so less withdrawal symptoms if missed dosing 2. Multiple successful medication trials in adolescents

Question 29

SSRI FDA approved for 12 and older first line?

Answer 29

Escitalopram (Lexapro)

Question 30

Escitalopram (Lexapro) 1. Start the dose at? 2. Effective dose at? 3. Max dose at?

Answer 30

1. Starting dose 5 mg daily 2. Effective dose 10-20 mg 3. Maximum dose 20 mg

Question 31

What are the rules for SSRIs? | 4

Answer 31

1. Don’t abruptly stop SSRI’s need to be tapered up and down 2. Don’t increase dose any more frequently then 4-6 week increments 3. Try to wait out mild side effects like HA and GI side effects for a week or so to see if they subside 4. Don’t stop med for SE just decrease it and see what happens (unless severe)

Question 32

Common SSRI side effects | 5

Answer 32

1. Headaches 2. GI upset 3. Insomnia 4. Agitation 5. Anxiety

Question 33

Other SSRI side effects

Answer 33

``` Dry mouth Constipation Sweating Sexual dysfunction Irritability Disinhibition Appetite changes Rash Serotonin syndrome Akathisia Hypomania Discontinuation syndrome ```

Question 34

SSRI black box warning??

Answer 34

Increased suicidality risk in children, adolescents, and young adults w/ major depressive or other psychiatric disorders; weigh risk vs. benefit; in short-term studies of antidepressants vs. placebo, suicidality risk not increased in patients >24 years old, and risk decreased in patients >65 years old.

Question 35

1. When should we follow up after putting them on an SSRI? 2. After a maintance dose? 3. Continually assess what? 4. What has the best response to treatment?

Answer 35

1. Follow up with these patients every week to 2 weeks at first 2. Once on maintenance dose follow up once a month for several months then move to quarterly 3. Continually assess suicidality 4. CBT or IPT PLUS meds have better response to treatment

Question 36

If no improvement in symptoms after 4-6 weeks of optimum dosing what should we do?

Answer 36

refer for mental health consultation (per guidelines but I would always start with referral due to long wait periods)