The American Academy of Pediatrics (AAP) recently published new guidelines to help pediatricians identify and treat adolescents with depression. We spoke with psychiatrist Rachel A. Zuckerbrot, MD, co-author of the updated guidelines, about the changes that have occurred since the AAP last published recommendations over 10 years ago—and the increasing role of pediatricians in helping adolescents manage depression.
Q: The new AAP guidelines suggest all adolescents should be screened for depression, instead of just high-risk teens. What prompted the change?
A: Although the timing of the new guidelines happened to coincide with several newsworthy national trends—a rise in teen suicides, gun violence, and substance abuse—the main reason for the update was because the old guidelines were outdated. For instance, in the last decade, several additional psychiatric medications have been approved for use in adolescents, including one specifically for adolescent depression.
An estimated 20 percent of adolescents experience depression.
Also, thinking has changed in recent years about who to screen for depression, for a variety of reasons. An estimated 20 percent of adolescents experience depression, which can be persistent in this age group. Also, studies have shown that adolescents with depression can have serious problems during adulthood. Screening all adolescents rather than focusing on high-risk adolescents—such as those with a personal or family history of mental illness, substance abuse, or trauma—might improve our ability to identify depression in this age group.
In addition, the new AAP guidelines now match recommendations from the U.S. Preventive Services Task Force, issued in 2009, which called for universal depression screening in adolescents.
Q: About half of all adolescents with depression are undiagnosed—why so many?
A: Depression tends to be an internalizing disorder. In some teens there may be no obvious outward signs of a problem. It’s different from, say, attention deficit-hyperactivity and learning disorders, which can cause behavioral problems that may be noticed by a parent or teacher. When adolescents with depression do act out, they may be labeled as ‘problem’ teens, and that label prevents them from getting the care they need. In addition, many teens simply don’t talk to their parents or teachers when they are feeling depressed.
Q: Do the guidelines tell physicians how to look for depression in teens?
A: The new guidelines call for annual depression screening in all adolescents, starting at age 12, with a paper or electronic self-report tool that can be filled out in private. Privacy is important, because teens may answer differently in front of their parents. In addition, pediatricians are encouraged to look for depression risk factors starting at age 10, and then screen for depression in those with risk factors.
The new guidelines also clearly outline the stages of depression, which have different treatments depending on severity. We wanted to emphasize the idea that primary care pediatricians can treat patients with mild and sometimes moderate depression, but may consider referring patients with moderate to severe depression to pediatric psychiatrists or other specialists.
Q: Do adolescents and families know that they can turn to their pediatrician for help with diagnosing and treating depression?
Pediatricians can help [teens] with mental and behavioral health problems.
A: A lot of families may only think of their pediatrician as someone who gives vaccinations and addresses physical ailments like skinned knees or infectious diseases. The AAP has been trying to get the message out to families that pediatricians can also help with mental and behavioral health problems. As pediatricians prepare to do universal depression screening in adolescents, they may use it as an opportunity to communicate about it with families. For instance, some pediatric practices have sent out letters to their patients and families explaining that they plan to meet with teens in private during their annual checkup to talk about emotional heath. Though input from the family is essential in treating adolescent depression, teens must also be given the opportunity to speak privately with their physicians to confide things they may not feel comfortable discussing in front of their parents.
Q: Why is the age range mentioned in the guidelines (10 to 21 years) so broad?
A: There is a subset of younger kids who pediatricians regard as developmentally similar to teens. In such children, it’s entirely possible to detect depression risk factors as in any post-pubertal youth who is at risk.
Pediatricians usually continue to see patients until they are 21, so we extended depression screening to include these young adults. However, it’s up to the individual clinician to decide whether to diagnose and treat the older patient using adolescent or adult guidelines. For example, involvement of the family may be less appropriate for certain young adults, and a much larger armamentarium of medications has been shown to successfully treat depression in those age 18 and older.
Q: What kind of support can pediatricians get to help them identify and treat adolescents with depression?
A: Since the 1970s, social, emotional, and behavioral issues that affect health—known as ‘the new morbidity’—have become more prevalent than infectious and chronic diseases in pediatric practice. However, the training that pediatricians get in medical school and residency hasn’t kept pace with this trend.
The REACH Institute, which includes national leaders in child psychiatry, psychology, and pediatrics, offers a variety of resources to help pediatricians address emotional and behavioral issues, including psychiatric disorders. They’ve put together a mental health toolkit to help providers put the new depression guidelines into effect.
Rachel A. Zuckerbrot, MD, is an associate professor of clinical psychiatry at Columbia University Vagelos College of Physicians and Surgeons. She is an active participant in a consortium of academic medical centers in New York state known as Project TEACH (Training and Education for the Advancement of Children’s Health).