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Complete Summary

GUIDELINE TITLE

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management.

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

This is the current release of the guideline.

COMPLETE SUMMARY CONTENT

 SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 QUALIFYING STATEMENTS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

Depression (major depressive disorders)

GUIDELINE CATEGORY

Counseling
Diagnosis
Evaluation
Management
Risk Assessment

CLINICAL SPECIALTY

Family Practice
Nursing
Pediatrics
Psychiatry
Psychology

INTENDED USERS

Advanced Practice Nurses
Allied Health Personnel
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers

GUIDELINE OBJECTIVE(S)

To assist primary care clinicians in the management of adolescent depression

TARGET POPULATION

Adolescents (youths aged 10 to 21 years) in primary care settings in the US and Canada

Note: This age range was chosen to include those who might be developmentally "adolescent."

INTERVENTIONS AND PRACTICES CONSIDERED

Identification/Assessment/Diagnosis

  1. Assessment of risk factors
  2. Use of systematic identification strategies (e.g., Guidelines for Adolescent Preventive Services, Strength and Difficulties Questionnaire, Beck Depression Inventory, Kutcher Adolescent Depression Scale, mnemonic-based interviews, brief symptom checklist, and validated depression scales)
  3. Use of established diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV]; International Classification of Diseases, 10th Revision)
  4. Use of standardized depression assessment tools
  5. Assessment of comorbidities
  6. Safety assessment

Initial Management

  1. Patient and family education and counseling
  2. Treatment planning, including goal setting and patient monitoring
  3. Establishment of links with mental health resources
  4. Establishment of a safety plan, including removal of methods of suicide and establishment of emergency communication mechanisms

MAJOR OUTCOMES CONSIDERED

  • Rate of identification of adolescent depression
  • Sensitivity, specificity, positive predictive value, negative predictive value, and area under the curve for depression assessment tools
  • Scores on standardized depression scales
  • Impairment in function
  • Rate of referral to mental health care
  • Rate of improvement in comorbid conditions
  • Rate of use of related services
  • Patient/family satisfaction
  • Suicide rate
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METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

  1. To understand the problems and obstacles faced by primary care (PC) clinicians regarding the management of adolescent depression, the guideline steering group first conducted focus groups with PC clinicians and youth patients and their family members to review issues pertinent to the PC management of depression.
  2. Systematic literature reviews were conducted in each of 5 key areas in which recommendations were subsequently developed. Whenever possible, these reviews focused on identifying empirical evidence that was developed within child/adolescent PC settings. When PC studies were unavailable, research from specialty mental health care was reviewed. In all 5 review instances, the Guidelines for the Management of Adolescent Depression in Primary Care (GLAD-PC) team first determined the existence of all high-quality, previously published, systematic evidence-based reviews that met the following criteria: (a) clear definition of search terms from Medline, including words and word roots; (b) explicit delineation of years searched; (c) exclusion of non–English-language studies; (d) physical review and reading of search-identified titles and abstracts; and (e) selection, review, and reading of possibly relevant articles before determination of final inclusion. When more than 1 systematic evidence-based review was identified for a given area, all reviews were drawn on to identify relevant articles for potential inclusion. More than 1 systematic evidence-based review was available for the areas of efficacy of psychotherapeutic interventions for youth major depressive disorder (MDD) and efficacy of pharmacologic treatments for youth MDD. For all reviews, when appropriate, the team updated the review for any ensuing years transpired since the latest review by using these same 5 methods. When systematic reviews were not available for a given area, the GLAD-PC team conducted a systematic review by using Medline (from inception to 2004/2005) and the criteria described above. Reviews were guided by members of the GLAD-PC Steering Committee, which comprised leading experts in each of these areas.

To address the first key area regarding the identification and assessment of adolescent depression in PC, a systematic evidence review was conducted to identify all available evidence about adolescent depression identification in PC, as well as information regarding current practices. This review has since been published. Because of limited information about depression assessment and screening measures in PC specifically, the team also reviewed adolescent-screening instruments/tools previously used in psychiatric or community populations. Beginning from 2 previous systematic evidence reviews, the GLAD-PC team performed an additional systematic review from 1998 to 2004.

To address the second key area regarding the initial management of adolescent depression in PC, a systematic evidence review was conducted to identify all available evidence about interventions for adolescent depression in PC and has since been published as well. Other evidence for the initial management of adolescent depression in PC came from systematic evidence reviews that addressed the chronic illness model, systems of care, and safety planning for suicidal patients.

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

See the Oxford Centre for Evidence-Based Medicine (www.cebm.net/levels_of_evidence.asp).

METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Consensus Development Conference)

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

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.

On the basis of the questions and issues identified during the focus groups and the literature reviews, the Guidelines for the Management of Adolescent Depression in Primary Care (GLAD-PC) Steering Group developed a survey to answer questions regarding critical issues in PC management of adolescent depression that have not been answered in the empirical literature. The survey questions were developed and reviewed by clinical and research experts in the area of mental health and PC. Using this survey, research and clinical experts were surveyed on their depression assessment and management recommendations. Depression clinical/research experts (N = 81) from Canada and the United States were asked to complete the 34-item study survey. Of these items, 3 questions dealt with the identification and diagnosis of depression. Subjects were chosen by using 1 of 4 criteria: (a) membership in child and adolescent psychiatric organizations in Canada and the United States including their academies of child and adolescent psychiatry; (b) recipient of federal grants for related research; (c) lead author of at least 2 articles on clinical research in the area from 1999 to 2004 on the basis of Medline citations; or (d) key PC clinical and research leader with expertise in the area of guideline development and/or emotional and behavioral disorders that present in PC settings.

An expert consensus workshop was held in July 2004 with North American experts on depression, clinical pediatrics, quality improvement, mental health policy, and health economics. Published data from the literature review, unpublished high-quality research currently in process of publication, and the results of the survey were presented to guide the initial discussion and consensus process.

Guidelines were developed on the basis of multiple iterations shared among a small group of core writers, guidance of the larger steering group, and ultimate input of all consensus-conference attendees to obtain full ownership of the final product.

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Each recommendation is graded on the basis of the Oxford Centre for Evidence-Based Medicine grade of evidence (A–D) system (see www.cebm.net/levels_of_evidence.asp). In addition, the strength of each recommendation, in terms of the extent to which experts agreed that the recommendation is highly appropriate and a "first-line" practice, was reached for each recommendation. Recommendation strength was rated in 4 categories: very strong (>90% agreement), strong (>70% agreement), fair (>50% agreement), and weak (<50% agreement). The recommendations in the guidelines were developed only in areas of management that had at least "strong agreement" among experts.

COST ANALYSIS

A formal cost analysis was not performed and published cost analyses were not reviewed.

METHOD OF GUIDELINE VALIDATION

Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

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RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Definitions for grades of evidence (A-D) and strengths of recommendation (weak, fair, strong, very strong) are provided at the end of the "Major Recommendations" field.

Identification

Recommendation 1: Patients with depression risk factors (such as history of previous episodes, family history, other psychiatric disorders, substance abuse, trauma, psychosocial adversity, etc) should be identified (grade of evidence: C; strength of recommendation: very strong) and systematically monitored over time for the development of a depressive disorder (grade of evidence: C; strength of recommendation: very strong).

Assessment/Diagnosis

Recommendation 1: Primary care (PC) clinicians should evaluate for depression in adolescents at high risk as well as those who present with emotional problems as the chief complaint (grade of evidence: B; strength of recommendation: very strong). Clinicians should assess for depressive symptoms on the basis of diagnostic criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) or International Classification of Diseases, 10th Revision (grade of evidence: B; strength of recommendation: very strong) and should use standardized depression tools to aid in the assessment (grade of evidence: A; strength of recommendation: very strong).

Recommendation 2: Assessment for depression should include direct interviews with the patients and families/caregivers (grade of evidence: B; strength of recommendation: very strong) and should include the assessment of functional impairment in different domains (grade of evidence: B; strength of recommendation: very strong) and other existing psychiatric conditions (grade of evidence: B; strength of recommendation: very strong).

Initial Management of Depression

Recommendation 1: Clinicians should educate and counsel families and patients about depression and options for the management of the disorder (grade of evidence: C; strength of recommendation: very strong). Clinicians should also discuss limits of confidentiality with the adolescent and family (grade of evidence: D; strength of recommendation: very strong).

Recommendation 2: Clinicians should develop a treatment plan with patients and families (grade of evidence: C; strength of recommendation: very strong) and set specific treatment goals in key areas of functioning, including home, peer, and school settings (grade of evidence: D; strength of recommendation: very strong).

Recommendation 3: The PC clinician should establish relevant links/collaboration with mental health resources in the community (grade of evidence: B; strength of recommendation: very strong), which may include patients and families who have dealt with adolescent depression and are willing to serve as resources to other affected adolescents and their family members (grade of evidence: D; strength of recommendation: very strong).

Recommendation 4: All management must include the establishment of a safety plan, which includes restricting lethal means, engaging a concerned third party, and developing an emergency communication mechanism should the patient deteriorate, become actively suicidal or dangerous to others, or experience an acute crisis associated with psychosocial stressors, especially during the period of initial treatment when safety concerns are highest (grade of evidence: C; strength of recommendation: very strong).

Definitions:

Grades of Evidence

Each recommendation is graded on the basis of the Oxford Centre for Evidence-Based Medicine grade of evidence (A–D) system (see www.cebm.net/levels_of_evidence.asp).

Strengths of Recommendation

The strength of each recommendation, in terms of the extent to which experts agreed that the recommendation is highly appropriate and a "first-line" practice, was reached for each recommendation. Recommendation strength was rated in 4 categories:

  • Very strong (>90% agreement)
  • Strong (>70% agreement)
  • Fair (>50% agreement)
  • Weak (<50% agreement)

CLINICAL ALGORITHM(S)

The original guideline document contains a clinical algorithm for "Preparation for Managing Depression in Primary Care."

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EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence is identified and graded for each recommendation (see "Major Recommendations").

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BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

  • Effective identification, assessment, and initial management of adolescent major depressive disorders in primary care settings
  • Prevention of suicide

POTENTIAL HARMS

Not stated

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QUALIFYING STATEMENTS

QUALIFYING STATEMENTS

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.

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IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

Preparatory Steps

Because the management of adolescent depression may constitute a new or major challenge for some primary care (PC) practices, a number of important considerations should be kept in mind when preparing to implement the guidelines, given the findings from studies in the adult literature, input from focus groups with clinicians, families and patients, and the experience of members of the Guidelines for the Management of Adolescent Depression in Primary Care (GLAD-PC) Steering Committee. Specifically, PC clinicians who manage adolescent depression should pursue (1) additional education regarding issues such as advances in screening, diagnosis, treatment, and follow-up, liability, consent, confidentiality, and billing, (2) practice and systems changes such as office staff training and "buy-in," electronic medical charts, and automated tracking systems, whenever available, and (3) establishing linkages with mental health services.

Linkages with community mental health resources are necessary to both meet the learning needs of the PC clinician and facilitate consultation/referral of difficult cases. Practice and systems changes are useful in increasing clinicians' capacity to ensure monitoring and follow-up of patients with depression. For example, staff training may help prioritize calls from adolescent patients who may not state the nature of their call. Specific tools and/or templates have been developed that offer examples of how to efficiently identify, monitor, track, and refer teens with depression. These materials are available in the GLAD-PC toolkit (available at www.glad-pc.org). The toolkit addresses how each of the recommendations might be accomplished without each practice necessarily having to "reinvent the wheel."

IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms
Clinical Algorithm
Foreign Language Translations
Patient Resources
Tool Kits

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

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INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Getting Better
Living with Illness

IOM DOMAIN

Effectiveness
Patient-centeredness

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IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2007 Nov

GUIDELINE DEVELOPER(S)

Guidelines for Adolescent Depression in Primary Care (GLAD-PC)

SOURCE(S) OF FUNDING

Guidelines for Adolescent Depression in Primary Care (GLAD-PC)

GUIDELINE COMMITTEE

Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Steering Group

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Authors: Rachel A. Zuckerbrot, MD, Division of Child Psychiatry, Department of Psychiatry, Columbia University/New York State Psychiatric Institute, New York, New York; Amy H. Cheung, MD, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Peter S. Jensen, MD, REACH Institute, Resource for Advancing Children's Health, New York, New York; Ruth E. K. Stein, MD, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; Danielle Laraque, MD, Department of Pediatrics, Mount Sinai School of Medicine, New York, New York

GLAD-PC Project Team Members: Peter S. Jensen, MD (project director, REACH Institute); Amy Cheung, MD (project coordinator, University of Toronto/Columbia University); Rachel A. Zuckerbrot, MD (project coordinator, Columbia University); Kareem Ghalib, MD (Columbia University); Anthony Levitt, MD (project consultant, University of Toronto)

GLAD-PC Steering Committee Members: Boris Birmaher, MD (Western Psychiatric Institute & Clinic, University of Pittsburgh); John Campo, MD (Ohio State University and Nationwide Children's Hospital); Greg Clarke, PhD (Center for Health Research, Kaiser Permanente); Dave Davis, MD (University of Toronto); Angela Diaz, MD (Mount Sinai School of Medicine); Allen Dietrich, MD (Dartmouth Hitchcock Medical Center); Graham Emslie, MD (University of Texas Southwestern Medical School); Bernard Ewigman, MD (Department of Family Medicine, University of Chicago); Eric Fombonne, MD (McGill University); Sherry Glied, PhD (Columbia University); Kimberly Eaton Hoagwood, PhD (Office of Mental Health, New York State/Columbia University); Charles Homer, MD (National Initiative for Children's Healthcare Quality); Danielle Laraque, MD (AAP New York Chapter 3, District II/Mount Sinai School of Medicine); Miriam Kaufman, MD (Hospital for Sick Children, University of Toronto); Kelly J. Kelleher, MD (Ohio State University); Stanley Kutcher, MD (Dalhousie Medical School); Michael Malus, MD (Department of Family Medicine, McGill University); James Perrin, MD (Massachusetts Medical School/Harvard Medical School); Harold Pincus, MD (Columbia University/New York State Psychiatric Institute); Brenda Reiss-Brennan, APRN (Intermountain Health); Diane Sacks, MD (Canadian Paediatric Society); Ruth E. K. Stein, MD (Forum for Child Health, New York Academy of Medicine, Albert Einstein College of Medicine); Bruce Waslick, MD, Baystate Health Systems, MA)

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Dr Cheung was on the speakers' bureau of Eli Lilly (2004-2005); Dr Jensen has received several unrestricted educational grants from Eli Lilly, McNeil, and Janssen-Ortho, is a consultant for Shire-Richwood, UCB Pharma, McNeil, and Janssen-Ortho, and is on the speakers' bureau for UCB Pharma, McNeil, and Janssen-Ortho. The other authors have indicated they have no financial relationships relevant to this article to disclose.

ENDORSER(S)

American Academy of Child and Adolescent Psychiatry - Medical Specialty Society
Canadian Academy of Child Psychiatry - Medical Specialty Society
Canadian Association for Adolescent Health - Medical Specialty Society
Canadian Paediatric Society - Medical Specialty Society
Canadian Psychiatric Association - Medical Specialty Society
College of Family Physicians of Canada - Professional Association
Depression and Bipolar Support Alliance - Disease Specific Society
Federation of Families for Children's Mental Health - Medical Specialty Society
Mental Health America - Medical Specialty Society
Mental Health Association of New York City - Professional Association
National Alliance on Mental Illness - Private Nonprofit Organization
National Association of Pediatric Nurse Practitioners - Professional Association
Society for Adolescent Medicine - Medical Specialty Society
Society for Developmental and Behavioral Pediatrics - Professional Association

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available from the Pediatrics journal Web site.

Print copies: Available from Rachel A. Zuckerbrot, MD, Columbia University, Division of Child Psychiatry, Department of Psychiatry, 1051 Riverside Drive, Unit 78, New York, NY 10032. E-mail: raz1@columbia.edu.

AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

PATIENT RESOURCES

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC STATUS

This NGC summary was completed by ECRI Institute on May 30, 2008. The information was verified by the guideline developer on August 18, 2008.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.
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