Pediatric Depression and Suicide: An Update for School Nurses

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Pediatric Depression and Suicide An Update for
School Nurses

• W. Burleson Daviss, MD
• Dept. of Psychiatry
• University of Texas Health Science Center
• at San Antonio

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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).

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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

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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

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Mania Mnemonic

• Markedly elevated or irritable moods and
• 3-4 GRRAPID symptoms
• Grandiosity
• Racing thoughts
• Reckless pleasure-seeking behavior
• Activity increased (goal-directed)
• Pressured speech
• Insomnia decreased need for sleep
• Distractibility

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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

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Bipolar Disorders in Children

• Rapid cycles
• Mixed episodes
• Often occur with psychotic symptoms
• Positive family history of bipolar disorder

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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

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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

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Suicide 3rd Leading Cause of Death in Youths
Ages 15-19 U N I T E D S T A T E S, 2001
CAUSE OF DEATHS Accidents 6646 Homicide 1899 Sui
cide 1611 Cancer 732 Heart Disease 347 Congenital
Anomalies 255 Chronic Lower Respiratory
Disease 74 Stroke 68 Influenza and
Pneumonia 66 Blood Poisoning 57
1599
Anderson Smith 2003
C.E14
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Environmental factors

• Traumatic exposure and other adverse life events
• Family conflicts
• Parental stress
• Peer problems
• School problems
• Are these a cause or an effect?

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Heritability

• How much of the disorder is due to inherited,
  genetic factors (Nature) as opposed to
  environmental factors (Nurture)?

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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.

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Pediatric DepressionChallenges of Assessment
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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

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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

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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

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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 gt
  somatic/vegetative sxs

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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

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Assessment Strategies for Pediatric Depression
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Diagnostic Work Up History

• Review history of psychiatric symptoms
• Review medical problems
• Review familys mental health history
• Assess childs function at school, with peers,
  and at home
• Review stressors that may be contributing

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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

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Rating Scales General Scales

• Child Behavior Checklist, Teachers 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.ouh
  sc.edu/rokplay.asp

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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

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Rating Scales for Depression

• Beck Depression Inventory
• Childrens 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

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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 gt 24
• Scores on short version gt 7

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Diagnostic Work Up Mental Status Exam (MSE)

• Activity level
• Spontaneity
• Eye contact
• Affect
• Mood
• How do you feel talking to this kid?

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MSE Thought Content

• Self esteem
• Hopelessness
• Helplessness
• Delusions
• Hallucinations
• Suicidal thoughts or behaviors

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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 theyd 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?

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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?

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Treatment
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Two Main Treatment Options

• Psychosocial
• Pharmacological

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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

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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

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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

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CDRS Adjusted Means (ITT)
TADS Team (2004), JAMA 292 807-820
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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

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Depressed Child or 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 Referral
• Compensation available
• Continued care if applicable

• Call us at 210-562-5400 for more information

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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

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Why Use Antidepressants At All? US
Epidemiological Studies, Ages 15-24
Rate per100,000
Anderson 2002, CDC Wonder 2003, USDHEW 1956,
Vital Statistics U.S. 19541978
C.E16.XX
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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
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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
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School Nurses 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

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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
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Summary

• Pediatric depression a potentially devastating
  problem, if undiagnosed or untreated
• Weve reviewed risk factors, signs and symptoms
  of pediatric depression and suicide
• Weve discussed strategies for assessment and
  treatment, especially in school setting

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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 childrens response
  to treatment

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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/

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Thanks!!!
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Appendices

• Vanderbilt Teachers Rating Scale
• Vanderbilt Parents Rating Scale
• Vanderbilt Parents 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