Last month, we introduced you to 15-year-old Jane, a teenager whose once bubbly personality had in the last few months been reduced to a mood of quiet sadness. Her responses to your questions were muted, unenthusiastic. While Jane gets to school every day and can often shake off her down mood when she’s with friends, her responses to the Kutcher Adolescent Depression scale suggest that she’s struggling. You conclude that Jane is experiencing an episode of mild depressive disorder.
How would you manage Jane’s case? And what would you do if her symptoms worsened?
What’s the preference of patient and family?
Begin your initial management of a patient like Jane by considering the treatment preferences of the patient and her family, the severity and urgency of the case, the availability of mental health services, and your own comfort level with managing mental health disorders. A key conclusion of the GLAD-PC (GuideLines for Adolescent Depression in Primary Care) collaborative, described in Part 1 of this series, was that family physicians, alone or in collaboration with mental health professionals, are competent to manage adolescent depression.1 You may or may not choose to manage a patient like Jane yourself, but even if you refer, your initial management provides an essential bridge until the patient and her family are seen by mental health professionals.
Your initial management should include the following:
- education
- a treatment plan
- safety planning.
Step 1: Educate patient and parents
Help your patient to better understand what it means to have depression. Describe the signs and symptoms that led to the diagnosis of depression and review the natural history of the illness, including the chronic nature of the disorder and its tendency to recur. Explain, too, the impact that depression can have on different areas of functioning, such as school performance and peer relationships, and then review the treatment options. You or someone on your staff can provide this patient education initially, but it is also critical to connect the family to specific community resources for additional education, advocacy, and peer support.1
To do this effectively, you need to establish links with mental health resources in the community, including mental health service providers, as well as patients and families who have dealt with adolescent depression and are willing to serve as resources to other teens and their families. The GLAD-PC toolkit, available at www.gladpc.org, provides patient education handouts and links to reputable Web sites, advocacy organizations, and peer support groups. Additional online resources are listed in TABLE 1.
TABLE 1
Online resources
| SOURCE | WEBSITE |
|---|---|
| American Academy of Child and Adolescent Psychiatry | http://www.aacap.org/cs/root/facts_for_families/the_depressed_child |
| Families for Depression Awareness | www.familyaware.org |
| National Alliance on Mental Illness | http://www.nami.org/depression |
| National Institute of Mental Health | http://www.nimh.nih.gov/health/publications/depression |
Step 2: Work out a treatment plan
Developing a treatment plan that the patient and her parents can accept is critical. A plan that includes psychotherapy with a mental health provider, for example, won’t be acceptable to some patients and parents. They may refuse to participate, or their underlying mistrust may affect the outcome of treatment.2,3 Other families may reject any therapeutic approach that includes psychotropic drugs.
Expectations about the benefits of treatment influence outcomes significantly, so that, too, is a topic to explore as the treatment plan is worked out.3,4 Finally, the plan should include agreed-upon goals of treatment. For Jane, planned goals might include getting back into gymnastics or trying out for the school play.
Step 3: Plan for safety
Suicidality, including ideation, behaviors, or attempts, is common among adolescents with depression.5,6 In studies of completed suicide, more than 50% of the victims had a diagnosis of depression.5 To keep your patient safe, develop an emergency communication mechanism for handling increased suicidality or acute crises. If the patient’s risk is high, as shown by a clear plan or intent, immediate hospitalization may be necessary.
If you determine that inpatient treatment is not needed, you need to be sure that adequate adult supervision and support are available; that the teenager does not have access to potentially lethal medications, knives and other sharp objects, or firearms; and that both the patient and parents understand that drugs and alcohol weaken inhibitions. You need to set up a contingency plan with the family that includes checking in with you at reasonable intervals to assure the teen’s safety.5
Establishing a safety plan is especially important during the period of diagnosis and initial treatment, when suicide risk is highest.6 Confidentiality is the norm in adolescent medicine, but a patient like Jane must understand that you will breach confidentiality if that is necessary to keep her safe from harm.