Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, Assessment, and Initial Management

Abstract

OBJECTIVES. To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This first part of the guidelines addresses identification, assessment, and initial management of adolescent depression in primary care settings.METHODS. By using a combination of evidence-and consensus-based methodologies, guidelines were developed by an expert steering committee in 5 phases, as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) draft revision and iteration among members of the steering committee.RESULTS. Guidelines were developed for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in primary care, including identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The identification, assessment, and initial management section of the guidelines includes recommendations for (1) identification of depression in youth at high risk, (2) systematic assessment procedures using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, (3) patient and family psychoeducation, (4) establishing relevant links in the community, and (5) the establishment of a safety plan.CONCLUSIONS. This part of the guidelines is intended to assist primary care clinicians in the identification and initial management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists but cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for adolescent depression management. Additional research that addresses the identification and initial management of depressed youth in primary care is needed, including empirical testing of these guidelines. 4,5 Even when diagnosed by PC physicians, only half of these patients are treated appropriately. 3 Furthermore, rates of completion of specialty mental health referral for youth with a recognized emotional disorder from general medical settings are quite low (J. V. Campo, MD, written communication, 2006).In view of the shortage of mental health clinicians and barriers to children having access to mental health professionals, the well-documented need for PC clinicians to learn how to manage this condition, the increasing evidence base available to guide clinical practice, increased selective serotonin reuptake inhibitor-prescribing rates in pediatric PC, 6,7 and new evidence that a multifaceted approach with mental health consultation may improve the management of depression in PC settings, [8][9][10][11] guidelines may be a necessary first step in the identification and management of depression in adolescents in PC. Unfortunately, no depression-management guidelines have been developed for use in the PC setting in the United S...

Evidence for the Management of Adolescent Depression

“…• 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.…”

“…35 GLAD-PC-I also recommends providing families with education about depression and treatment. 47 NICE and CPG suggest adolescents be offered advice about nutrition and sleep, and NICE also includes exercise and anxiety management. 34,48 CPG recommends that depression treatment uniformly include psychoeducation and active support.…”

“…36 For adolescents with moderate and severe depression, GLAD-PC-II recommends consultation with a mental health specialist and identifies CBT, IPT, or SSRI as the treatments of choice. 47,50 NICE recommends 3 months of CBT or IPT as a first-line treatment of moderate and severe depression, with medication added if there is no response in 4 to 6 sessions. 34 CPG recommends 8 to 12 weekly sessions of CBT or IPT treatment of moderate depression, with an SSRI, especially fluoxetine, added in severe cases or when there is a history of suicidal ideation.…”