You’ve known Jane since infancy. Now she’s 15 and in your office for her yearly checkup. As she comes into the exam room, you notice she’s gained a lot of weight since you saw her a year ago. She’s also missing the energy and sparkle that have always been such an engaging part of her personality. When you trot out your usual questions for teens—How’s school? Keeping up your grades? Going out for a team?—her answers are disquieting. School’s dull, her grades have gone downhill, and she’s dropped out of gymnastics. Her mother says Jane is irritable and sleeping a lot, and that worries her.
Could Jane be going through a bout of clinical depression?
Teen depression: Common, and commonly untreated
In North America, about 9% of all teenagers meet the criteria for depression at any given time, and prevalence rates in primary care are very likely higher.1 One study in the 1990s found approximately 28% of teens presenting to a primary care office met criteria for depression.2
Although adolescents with depression frequently seek care in the primary care setting, most are not identified or treated because of any number of barriers.3,4 First, mental illness continues to be highly stigmatized. As a result, many troubled teens (and parents of these teens) do not seek help.4 Second, mental health professionals trained to treat adolescents are in short supply, and most family physicians and other primary care clinicians feel inadequately trained, supported, or reimbursed for the management of this disorder.5 Third, the controversy over the safety and efficacy of antidepressants in the pediatric population has created an additional barrier to care.
In addition, while clinical guidelines for diagnosing and treating adolescent depression have been developed for specialty care settings,6 they are not easily transferred to primary care because of the significant differences between the primary and specialty care settings. Recognizing this gap in clinical guidance, a group of researchers and clinicians (including the authors of this report) from the United States and Canada established a collaborative to formulate primary care guidelines for adolescent depression (GuideLines for Adolescent Depression in Primary Care, or GLAD-PC). Details about the collaborative’s methods and recommendations were published in Pediatrics in 2007.7,8 The accompanying clinician toolkit is available at www.gladpc.org.
This review summarizes the collaborative’s key findings and recommendations and includes evidence from additional research published since the completion of GLAD-PC in 2007. For simplicity’s sake, we use the term “depression” to refer to what is more formally known as major depressive disorder (MDD).
Red flags that you are well positioned to spot
As a family physician, you have the advantage of knowing the families in your practice well and over a long time span. Drawing on that knowledge, you are well placed to spot the red flags that may signal depression in an adolescent patient.
Risk factors for the disorder are well known: a previous episode of depression, a family history of depression, the presence of other psychiatric disorders such as anxiety or attention deficit hyperactivity disorder (ADHD), substance abuse, or life stressors such as bereavement, abuse, or divorce. Teens with depression may complain of emotional problems, or turn up with repeated somatic complaints—headaches, stomach aches, fatigue—that have no apparent physiologic explanation. Their responses to general questions, such as “How is your mood?” or “Have you been sad?” may be worrisome. Or they may screen positive on self-report checklists such as the Beck Depression Inventory (BDI) or the Kutcher Adolescent Depression Scale (KADS), available for download at www.cprf.ca/education/Openmind2006/KADS11.pdf and free for use with permission.9,10
GLAD-PC Recommendation I: Patients with depression risk factors such as history of previous episodes, family history, other psychiatric disorders, substance abuse, trauma, or psychosocial adversity should be identified (strength of recommendation [SOR]: C, expert opinion and cohort studies) and systematically monitored over time for the development of a depressive disorder (SOR: C, expert opinion and cohort studies).
GLAD-PC Recommendation II: Family physicians should consider the diagnosis of depression in high-risk adolescents and those who present with emotional problems as their chief complaints (SOR: B, cohort studies and randomized controlled trials [RCTs]).
Routine screening of all adolescents for depression may be feasible, but the US Preventive Services Task Force concluded in 2002 that the evidence was insufficient to recommend for or against the practice.7,11,12 Expert opinion suggests that among adolescents at elevated risk for depression, depression checklists are useful during well-child and urgent care visits. However, families will likely find general questions more acceptable during acute care visits.10