This is the current release of the guideline.

Depression (major depressive disorders)

Assessment of Therapeutic Effectiveness
Counseling
Management
Risk Assessment
Treatment

Family Practice
Nursing
Pediatrics
Pharmacology
Psychiatry
Psychology

Advanced Practice Nurses
Physician Assistants
Physicians
Social Workers

To assist primary care clinicians in the treatment and ongoing management of adolescent depression in the primary care setting

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."

Treatment

1. Active support and monitoring
2. Selective serotonin reuptake inhibitors (fluoxetine, paroxetine, citalopram, sertraline, escitalopram)
3. Cognitive behavioral therapy (CBT)
4. Interpersonal therapy (IPT)
5. Combination pharmacotherapy and CBT or IPT
6. Monitoring for adverse treatment events

Ongoing Management

1. Goal and outcome tracking
2. Reassessment of diagnosis and treatment
3. Mental health referral
4. Coordination of care between primary care and mental health specialist care

• Assessment and screening scores
• Rate of improvement (reduction in symptoms, improved assessment scores) on therapy
• Rate of adverse event on pharmacotherapy
• Suicide and self-injury rate

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Searches of Unpublished Data

The literature-review approach used for all of the reviews was as follows. First, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) team identified the existence of high-quality, previously published, systematic evidence-based reviews that met the following criteria: (1) explicit definition of search terms and years covered; (2) exhaustive search of Medline; (3) reading of abstracts to determine relevance, followed by review of entire articles from relevant abstracts; (4) restriction to English-language journals only; (5) restriction to empirical articles; and (6) identification of any otherwise omitted citations from the reference sections from key reviews. In areas where there were no carefully executed and well-described systematic literature reviews had been recently conducted (i.e., Food and Drug Administration [FDA], Cochrane), the GLAD-PC team conducted a systematic review for primary studies for each area by using Medline (from inception to 2004/2005 based on the 5 criteria described above.

Three literature reviews were conducted for the GLAD-PC recommendations presented in this guideline: (1) nonspecific psychosocial interventions in pediatric PC, (2) antidepressant treatment, and (3) the use of psychotherapy. For the first review, the literature (Medline, PsycINFO, and the Cochrane database) was searched for articles that examined evidence for psychosocial interventions delivered in the PC setting. The reference lists of all relevant articles were searched for additional studies. In addition, experts in the field were consulted to identify additional studies. Given the paucity of randomized, controlled trials (RCTs) identified earlier in a review, studies with simple before-and-after comparisons were also included.

In the second review, the team examined the efficacy and safety of antidepressant medications in the pediatric population (aged 7 to 18). The studies were identified in 2 stages. Given the thorough reanalyses of safety data on both published and unpublished clinical trials completed by the FDA, all RCTs included in the FDA safety report were reviewed. Second, to ensure that additional studies not reported to the FDA were not missed, Medline and PsycINFO were searched. For a full description of the review, please refer to the published review.

In the final review, the team searched the literature for depression trials that examined the efficacy of psychotherapy. The search included all forms of psychotherapy including both individual and group-based therapies. The team not only identified individual studies but also high-quality systematic reviews given the extensive empirical literature in this area.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus (Consensus Development Conference)

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

Peer Review

Not stated

The original guideline document contains a "Clinical Management Flowchart."

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

• Timely and effective intervention for adolescents with major depressive disorders (MDD) in the primary care setting
• Improvement in depressive symptoms
• Improvement in overall functioning

Recent reanalyses of safety data from clinical trials of antidepressants have led to a black-box warning from the Food and Drug Administration (FDA) regarding the use of these medications in children and adolescents and a recommendation for close monitoring. The exact wording of the FDA recommendation is, "all pediatric patients being treated with antidepressants for any indication should be observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases."

Further information on adverse effects of antidepressants is described in the accompanying "toolkit" (See "Availability of companion documents" field).

Treatment with selective serotonin reuptake inhibitors (SSRIs - citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, and escitalopram) is contraindicated in patients taking monoamine oxidase inhibitors (MAOIs).

• These guidelines cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist primary care clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists.
• Although these guidelines cover a range of issues regarding the management of adolescent depression in the primary care setting, there were other controversial areas that were not addressed in these recommendations. These included such issues as universal screening, using a second antidepressant when patients' conditions fail to respond to an initial antidepressant, and the treatment of subthreshold symptoms. New emerging evidence may impact on the inclusion of such areas in future iterations of the guidelines and the accompanying toolkit. Many of these recommendations are made in the face of absence of evidence or lower levels of evidence.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

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

2007 Nov

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

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

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

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

Dr Cheung is on the speakers' bureau of Eli Lilly; 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.

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

This is the current release of the guideline.

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

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