The PCP’s Role in Managing Pediatric Depression

Childhood Depression: Introduction

 Editor’s note: The United States is facing a severe shortage of psychiatrists and psychiatric resources, particularly in terms of pediatric mental healthcare. As a result, primary care providers (PCPs) are playing an increasing role in screening for and managing psychiatric symptoms and illnesses in their young patients. Medscape recently interviewed Dr. Robert L. Findling, a child psychiatrist, and Dr. Larry Culpepper, a primary care physician, on how PCPs can effectively contribute to the recognition and management of pediatric depression and work with psychiatrists in a collaborative approach to treatment.

Childhood Depression: Introduction

Bret Stetka, MD

Posted: 11/19/2010

Editor’s note: The United States is facing a severe shortage of psychiatrists and psychiatric resources, particularly in terms of pediatric mental healthcare. As a result, primary care providers (PCPs) are playing an increasing role in screening for and managing psychiatric symptoms and illnesses in their young patients. Medscape recently interviewed Dr. Robert L. Findling, a child psychiatrist, and Dr. Larry Culpepper, a primary care physician, on how PCPs can effectively contribute to the recognition and management of pediatric depression and work with psychiatrists in a collaborative approach to treatment.

Medscape: How prevalent is child and adolescent depression and how often do you encounter it in your practice?

Larry Culpepper, MD, MPH: In the community we know that approximately 2% of children are experiencing depression at any time, and that before adolescence, there are similar rates in boys and girls. As family physicians or pediatricians, we see children whose parents are often concerned about a number of behavioral issues such as school problems, bullying, anger issues, losses in the family, and witnessing violence. Depending on a child’s social environment and family history, these fairly acute concerns often are colored by a longer term envelope of family tension, disruption or divorce, and even neglect. Families living in poverty and those immigrating may have physical deprivation and major disruption in social support in their background as well. So an initial challenge for the physician is to ask, “What is going on here?” often with the background concern of :What is the prognosis?” and a third professional concern, “Am I equipped to manage this?”

When I see a child with a new behavioral concern, one of the first things I ask myself is, “Do I really know and understand this family?” This may lead to my uncovering a wealth of information necessary for diagnosis and care of the child. As with adults, another initial question once I have sorted through the acute situation is whether there is a psychiatric diagnosis — such as depression — and consequent prognosis that might have contributed to the child’s role in the acute situation, and that itself needs care and monitoring?

Robert L. Findling, MD: Probably the most important thing that’s been noted by Dr. Culpepper is that he is cognizant that childhood and adolescent depression is relatively common and that clinicians should be looking for it in young people. Many youths with depression go unrecognized and untreated.

Some Useful Red Flags

Medscape: What are some useful red flags for both PCPs and psychiatrists in terms of screening for pediatric depression? Also, how does depression in young patients differ from that in adults?

Dr. Findling: Although the name of this syndrome is “depression,” it appears that many youngsters who suffer from major depression have irritability as their presenting mood state. That can make assessment difficult for several reasons. First, because youths may be irritable, the patient or their parents may deny being depressed because they are not sad. Another key challenge is that irritability in this patient population is very nonspecific. It is a common issue seen in this age group, both as part of normal independent strivings as well as a potential feature of a mental health diagnostic entity.

Dr. Culpepper: I agree — irritability is a tipoff for the physician to investigate further, particularly when it is a source of concern expressed by a child, adolescent, or parent. In my experience, raising irritability to a focus of professional concern is an indication of either a real concern in the child, a plea for help, a sign of stress in the family, or a signal that can lead to the recognition of a psychiatric condition.

Dr. Findling: Certainly irritability can be a “red flag.” No doubt about it. The real issue with irritability is that it is associated with so many psychiatric conditions — depression, bipolar illness, oppositional defiant disorder to name just a few. However, irritability may be associated with normal development as a youngster is gaining independence. For those reasons, irritability, when it is noted to be a concern, can be seen as an invitation for further exploration.

Dr. Culpepper: Recognizing depression is key to moving the child and adolescent patient on to treatment. While irritability is common in children as well as adolescents, the depressed individual will also report age-appropriate manifestations of the adult criteria of depression, including both mood and psychiatric symptoms along with somatic symptoms. Loss of interest may be reflected in behavioral changes like decreased engagement in social activities and retreat from family activities. If prolonged, and these episodes of depression can last for months or longer, they may lead to significant disruption in a child or teen’s social development at a time when this involves important developmental tasks. It also may result in marked decline in school performance.

Some children may reach out with dysfunctional activities, for instance experimentation with substances and other high-risk behaviors. In adulthood, depression often involves executive dysfunction and impairments in cognition, decline in coping skills and problem-solving, and a decline in self-image. For children and adolescents, this also occurs at a time when these skills and perceptions are developmentally key. The extreme consequence of these impairments may be for the child to come to harm, either unintended or intended. Suicidal ideation should always be probed; for instance, starting with a question such as, “Do you feel like you’d rather not wake up in the morning,” and progressing to investigating whether specific planning or preparation is present. For instance, a depressed adolescent who has begun to give away favorite things may be at significant risk for suicide.

Dr. Findling: As far as depression is concerned, it is important for clinicians to identify this condition if indeed it is present. Certainly, as mentioned, depression can have adverse impacts on multiple domains of a youngster’s life. Concerns about the tragedy of increased risk for suicide are real. However, besides the dysfunction, it should be remembered that patients with depression are indeed suffering because of the subjective experience of being depressed. For these reasons, youngsters with depression need to be accurately identified and effectively treated. However, it should be remembered that pediatric depression is often a recurrent condition. For that reason it is good to recall that care for these youths requires vigilance that extends beyond the presenting depressive episode.

Achieving Collaborative Management

Dr. Culpepper: Again — we are in agreement! The take-home points are that as we see kids with concerns that may signal depression or another psychiatric disorder, the pediatrician or family physician should dig deeper to confirm whether a significant problem exists, and then either confirm the diagnosis or refer to or consult with a mental health specialist who can. Once a diagnosis is clear, then the PCP’s role can change again. For some kids we can be the prescriber, although ideally most children will have some form of pediatric psychotherapy and supportive intervention that includes their parent(s).

If the PCP is not involved in directly providing the mental healthcare, we still have a major role. And that is to continue monitoring the child and family and encouraging the patient to stay in treatment and adhere to medication regimes. Often, the parent or child will be more comfortable discussing worries and concerns with a PCP they have known for years — this familiarity can allow us to better be sure that a child is improving or that treatment is modified as necessary. The collaborative care model is of great value for such families. Over the long term, we can also monitor appropriate preventive mental healthcare and be alert for any relapses. Also, depression is often a family affair, and once a child is diagnosed with depression it is reasonable to consider whether it is present in other children in the family or in the parents.

Dr. Findling: Dr. Culpepper is right. In many ways the PCP has substantial advantages compared with the newly-found mental health provider. Besides usually having a longer relationship, a pediatrician or family physician also has a longitudinal perspective on the patient. As we’ve mentioned already, so much hinges on accurate diagnosis. It is this longitudinal view that can be so important in helping ensure an accurate diagnosis.

Although Dr. Culpepper doesn’t overtly state it, I completely agree that involving PCPs in the delivery of healthcare is wise and advantageous. Considering the shortage of child/adolescent psychiatrists, incorporating pediatricians and family doctors into the provision of mental healthcare to the young can ensure that more vulnerable youths can actually get the care they deserve. Perhaps it should also be mentioned — as Dr. Culpepper wisely notes — that there is not just 1 model of collaborative care for youths receiving psychiatric services. Indeed, crafting a team, the components of which may vary from patient to patient, that most effectively meets the needs of the child/teenager and his/her family is the way to go.

Are PCPs Adequately Trained?

Medscape: Are PCPs adequately trained — and do they have the time — to participate in the mental health care of their young patients?

Dr. Culpepper: The fly in the ointment is that many PCPs, both pediatricians and family physicians, might not have the needed knowledge and skills to provide mental healthcare to children and adolescents. Also they just might not have the time, particularly when it comes to psychotherapy and family therapy. While pediatricians and family physicians do have behavioral medicine as part of their required residency curriculum, this training may not provide sufficient skill in diagnostic assessment and the use of pharmacotherapy in child and adolescent age groups. Also these interventions require regular use for clinicians to stay proficient. Pharmacotherapy has seen significant advances in recent years, and increased understanding of safe practices in the use of antidepressants in those younger than 18 years of age. Similarly, development of effective psychotherapies has occurred in recent years, but children will have access to them only if their treating physician is aware of them.

As we move into the future, Accountable Care Organizations and Patient Centered Medical Homes, to be successful, will need to reintegrate mental healthcare into primary care. This will require on-the-job upgrading of the abilities of many physicians already in practice. To some extent, the most important knowledge a physician requires is that of his or her own limitations. This should guide the development of the treatment team, and the development of collaborative care relationships that do allow the physician to initiate and manage many cases of pediatric depression in their practices. One innovative program here in Massachusetts is a consultation program organized through the auspices of the state chapter of the Academy of Pediatrics that facilitates a telephone consultation for pediatricians and family physicians needing psychiatric input on patients.

Dr. Findling: Looking ahead, Dr. Culpepper is absolutely correct. Reintegrating mental healthcare into primary care may be the best means by which to deliver mental healthcare. For established physicians in practice, the questions that often arise pertain to psychiatric medications. How does one prescribe them and provide ongoing monitoring? The key issue is that although medications may be helpful to some, the real challenges to mental health-related issues are assessment and diagnosis. PCPs need to have the time and skills to perform such evaluations. At present, the healthcare system does not always provide an environment where PCPs can spend the requisite time to adequately perform an initial assessment. This is critically important because the assessment results drive treatment and referrals to specialists.

Besides the current delivery system, the means by which we educate and train physicians probably deserves reconsideration. Do students graduating from medical school really know enough about mental health issues in primary care/general medical settings? Are residency programs providing adequate training so that our newest colleagues in primary care are adequately prepared to address psychiatric issues to a greater degree than they have in the past? Now this may be one man’s opinion, but based on the great number of patients with mental health issues that go untreated, my sense is that the answer to both questions is “no.”

In short, if we want to help our patients who suffer from emotional or behavioral issues better than we have in the past, systematic changes in our education, training, and healthcare delivery systems are required.

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