Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and Ongoing Management

Abstract

OBJECTIVES. To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This second part of the guidelines addresses treatment and ongoing management of adolescent depression in the primary care setting.METHODS. Using a combination of evidence-and consensus-based methodologies, guidelines were developed in 5 phases as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) revision and iteration among members of the steering committee.RESULTS. These guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in primary care, including (1) active monitoring of mildly depressed youth, (2) details for the specific application of evidence-based medication and psychotherapeutic approaches in cases of moderate-to-severe depression, (3) careful monitoring of adverse effects, (4) consultation and coordination of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and its evidence base are summarized.CONCLUSIONS. These guidelines cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist primary care clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of youth with depression in primary care is needed, including the usability, feasibility, and sustainability of guidelines and determination of the extent to which the guidelines actually improve outcomes of youth with depression. that up to 9% of teenagers meet criteria for depression at any one time, with as many as 1 in 5 teens having a history of depression at some point during adolescence. [1][2][3][4][5] In primary care (PC) settings, point prevalence rates are likely higher, with rates up to 28%. 6-10 Taken together, epidemiologic and PCspecific studies have suggested that despite relatively high rates, major depressive disorder (MDD) in youth is underidentified and undertreated in PC settings. 11 Because of barriers to adolescents receiving specialty mental health services, only a small percentage of depressed adolescents are treated by mental health professionals. 12 As a result, PC settings have become the de facto mental health clinics for this population, although most PC clinicians feel inadequately trained, supported, or reimbursed for the management of this disorder. [13][14][15][16][17][18] Although MDD management guidelines have been developed for specialty care settings (eg, see the American Academy of Child and Adolescent Psychiatry [AACAP] practice parameters 19 ) or for related problems such as suicidal ideation or attempts, 2...

Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions

“…The AAP released guidelines on the treatment of ADHD in 2000 and recommended a greater role for primary care for all mental health conditions in 2009, and an expert steering group in 2007 outlined ways PCPs could be involved with adolescents with depression. [4][5][6][7] These guidelines suggest PCPs ask about mental health issues at all visits; screen for mental health conditions; diagnose and monitor common, mild-to-moderate conditions; provide a treatment plan including psychiatric medications when necessary; and consult with or refer to a mental health specialist in complex cases. The recommendations follow the promotion of psychosocial care and its inclusion in primary care over the past half-century and address the long-standing shortage of mental health professionals for children.…”

Evidence for the Management of Adolescent Depression

“…34 The 49 and CPG and GLAD-PC-II recommend different treatment courses based on symptom severity. 48,50 Rationale and Evidence…”

“…• Guideline 34,35,[47][48][49][50] • Not searched • Quasi/nonexperimental [52][53][54][55][56][57][58][59][60] QI 3: Suicide risk assessment.…”

“…• Guideline 34,35,[47][48][49][50] • Meta-analysis/systematic review [71][72][73][76][77][78]83,84 • RCT 70,75,[79][80][81][82][85][86][87] • Quasi/nonexperimental 74 QI 5: Treatment initiation (antidepressant medication or psychotherapy).…”

“…• Guideline [33][34][35][36][47][48][49][50] • Not searched • Meta-analysis/systematic review [88][89][90][91][92] • RCT 85,[93][94][95][96] QI 6: Communication and documentation.…”