Riddle me this: Depression, suicide, and the screening imperative

It’s virtually impossible to check your phone for news headlines without seeing another child who has become a suicide statistic. Recent data show that suicide is the third-leading cause of death for young persons aged 10 to 24 years-approximately 4600 lives lost each year. Over 3400% more than that number attempt suicide and survive.

Kendrea’s cry

The story of 6-year-old Kendrea Johnson from Minnesota, who hung herself with a jump rope 2 days after Christmas, was heart stopping. The 2 notes she left dispelled investigators’ questions about whether her death was an accident. “I’m sorry,” read one. “I’m sad for what I do,” said the second. Almost as inconceivable is that Kendrea had tried suicide before and failed. Police found healed ligature marks on both sides of her neck.

Screen for life

Unlike other children and despite her ultimate crisis, Kendrea had actually been assessed as having both homicidal and suicidal thoughts and was receiving intensive treatment. Experts fear other children and teenagers are flying under the diagnostic radar, underscoring the crucial role of pediatricians and other healthcare providers to be vigilant for the subtle signs, to talk with parents and caregivers, and to screen the patients themselves.

A personal gut check

This month’s quiz will test your knowledge of key diagnostic points in the screening process for depression in primary care. You’ll test your knowledge against your peers on 5 key points. Each point gives you context for the correct answer-and, most importantly, provides valuable resources.

1. Which of the following are among the risk factors of child or adolescent depression?

a) Chronic health problems, such as asthma, diabetes, and epilepsy

b) Male gender

c) Medications

d) Current or prior substance use problems 

e) All of the above

f) A, C, D

Answer: F

Female gender is one of the risk factors identified for child or adolescent depression. Other risk factors include chronic health problems, medications, current or prior mental health problems that include substance use problems, exposure to adverse life events (loss, trauma, or maltreatment), older age, family history of mental health problems (such as depression and suicidality) or substance use problems, problems with family or peer relationships, and negative cognition/attribution style. Identification of these factors allow for more targeted and effective development and implementation of depression programs.

Sources

Forman-Hoffman VL, Viswanathan M. Screening for Depression in Pediatric Primary Care. Curr Psychiatry Rep. 2018;20:62.

2. In adolescents who are screened for depression, only those with moderate to severe depression show an increased use of healthcare resources and costs during the 12 months after screening.

True

False

Answer: False

Even mild levels of depression in adolescents are linked to their increased use of healthcare resources and subsequent increased costs within the first year after screening. This emphasizes the importance of screening for depression in children and adolescents for timely diagnosis and treatment to ensure depression is addressed. Studies show that the comorbidities associated with depression in childhood, including poor school and social functioning, problems with relationships, and obesity, can have lasting livelong effects. Despite the physical and mental health problems associated with depression, less than 50% of adolescents with major depression received treatment for depression in 2016.  

Sources

Forman-Hoffman VL, Viswanathan M. Screening for Depression in Pediatric Primary Care. Curr Psychiatry Rep. 2018;20:62. 

Wright DR, Katon WJ, Ludman E, et al. Association of Adolescent Depressive Symptoms With Health Care Utilization and Payer-Incurred Expenditures. Acad Pediatr 2016;16(1):82-9. 

Center for Behavioral Health Statistics and Quality. 2016 National Study on Drug Use and Health. Detailed Tables. Rockville: Substance Abuse and Mental Health Services Administration; 2017. 

3. Guidelines by several organizations responsible for child mental health recommend universal depression screening of depression in the pediatric primary care setting. Which of the following is not true?

A) Recommendations for universal depression screening in children is based on indirect evidence showing that the benefits of screening outweigh the potential harm, even in children without known high risk factors for depression.

B) One standard universal screening tool for pediatric depression is recommended for all primary care settings.

C) Barriers to screening and management of depression reported by primary care providers include lack of training in assessing and managing depression as well as uncertainty about the use of common antidepressants in children given the black box warning by the FDA in 2004 about the potential for increased suicidality associated with these drugs.

D) Critical opportunities to identify and initiate treatment for depression in children and adolescents are missed because of barriers that inhibit widespread implementation of depression screening.

Answer: B

Universal screening for depression is recommended by a number of organizations, including the 2018 Guidelines for Adolescent Depression in Primary Care (GLAD-PC), the 2016 US Preventive Services Task Force (USPSTF), the 2015 National Institute for Health and Care Excellence (NICE), and 2007 American Academy of Child and Adolescent Psychiatry (AACAP). To date, the recommendations are based on indirect evidence from systematic review of the current literature that support the benefits of screening given the lack of direct evidence on outcomes associated with screening.

Although all organizations recommend universal screening, no single screening tool is recommended. Rather, primary care providers are urged to choose the best screening tool among the various types of screening tools deemed applicable to primary care settings that best fits their practice.

Given the lack of direct evidence of outcomes associated with depression screening in children, more research is needed on the direct net benefits of screening as well as how identify factors to implement effective screening in clinical practice.

Source

Forman-Hoffman VL, Viswanathan M. Screening for Depression in Pediatric Primary Care. Curr Psychiatry Rep. 2018;20:62. 

Forman-Hoffman VL, McClure E, McKeeman J, et al. Screening for Major Depressive Disorder in Children and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force. Evidence synthesis no. 116. AHRQ publication no. 13-05192-EF-1. Rockville, MD: Agency for Healthcare Research Quality; 2016.

Fallucco EM, Seago RD, Cuffe SP, et al. Primary care provider training in screening, assessment, and treatment of adolescent depression. Acad Pediatr 2015;15(3):326-32.

Zuckerbrot RA, Cheung A, Jensen PS, et al. Guidelines for adolescent depression in primary care (GLAD-PC): part I. Practice preparation, identification, assessment, and initial management. Pediatrics 2018;141e20174081.

Cheung AH, Zuckerbrot RA, Jensen PS, Guidelines for adolescent depression in primary care (GLAD-PC): part II. Treatment and ongoing management. Pediatrics 2018;141:e20174082.

Forman-Hoffman V, McClure E, McKeeman J. et al. Screening for major depressive disorder in children and adolescents: a systematic review for the U.S. preventive services task force. Ann Intern Med 2016;164(5):342-9.

Siu AL, Force USPST. Screening for depression in children and adolescents: U.S. preventive services task force recommendation statement. Ann Intern Med 2016;164(5):360.

Hopkins K, Crosland P, Elliott N, et al. Diagnosis and management of depression in children and young people: summary of updated NICE guideline. BMJ 2015;350:h824.

Birmaher B, Brent D, Bernet W, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 2007;46(11):1503-26.

4. Evidence shows that depression screening is useful only in adolescents at least 12 years of age, the typical age of onset for clinically significant major depressive disorder.

True

False

Answer: False

Although most research on screening for depression in children has been done in adolescents 12 years or older, the benefits of depression screening in younger children is unknown. More research is needed to look at the benefits of screening in younger children, as well as other factors that are poorly understood when it comes to depression screening in younger children. These factors include the role of parents in accepting screening of younger children, as well as how to diagnose and treat depression in younger children.

Source

Forman-Hoffman VL, Viswanathan M. Screening for Depression in Pediatric Primary Care. Curr Psychiatry Rep. 2018;20:62.

5. Since the 2004 FDA advisory that selective serotonin reuptake inhibitors (SSRIs) may potentially increase suicidality in children younger than 18 years age, which of the following is not true regarding the use of these antidepressants for pediatric patients?

A) Newer research showing no such increase in the potential for suicidality with SSRIs in children younger than 18 years of age have increased their use in the primary care setting.

B) Prescriptions for SSRIs for children has decreased by 22% since the 2004 FDA advisory.

C) The decreased use of SSRIs was associated with a 14% increase in suicide rates in children and adolescents between 2003 and 2004.

D) None of these are true.

Answer: A

Primary care providers continue to be reluctant to prescribe medications for depression in children and adolescents, despite their known efficacy, because of the belief these drugs may increase suicide risk in children and adolescents. Data show an uptick in suicides in children and adolescents associated with a decrease in prescribing SSRIs, however. An increased suicide rate by 14% between 2003 and 2004 is associated with a 22% decrease in prescribing SSRIs. This increase in suicide rates in children and adolescents is the largest change in the year-to-year suicide rates since 1979 when the Centers for Disease Control and Prevention (CDC) began to collect suicide data on this population.

Source

Forman-Hoffman VL, Viswanathan M. Screening for Depression in Pediatric Primary Care. Curr Psychiatry Rep. 2018;20:62.

Williams J, Klinepeter K, Palmes G, et al. Behavioral health practices in the midst of black box warnings and mental health reform. Clin Pediatr (Phila) 2007;46(5):424-30.

Gibbons RD, Brown CH, Hur K, et al. Relationship between antidepressants and suicide attempts: an analysis of the veterans health administration data sets. Am J Psychiatry 2007;164(7):1044-9.