Depression: Cheung AH

Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque D, Stein RE, Anonymous00327. · University of Toronto, Department of Psychiatry, 33 Russell St, 3rd Floor Tower, Toronto, Ontario, Canada M5S 2S1. · Pediatrics. · Pubmed #17974724 links to  free full text

Abstract: OBJECTIVES: To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This second part of the guidelines addresses treatment and ongoing management of adolescent depression in the primary care setting. METHODS: Using a combination of evidence- and consensus-based methodologies, guidelines were developed in 5 phases as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) revision and iteration among members of the steering committee. RESULTS: These guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in primary care, including (1) active monitoring of mildly depressed youth, (2) details for the specific application of evidence-based medication and psychotherapeutic approaches in cases of moderate-to-severe depression, (3) careful monitoring of adverse effects, (4) consultation and coordination of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and its evidence base are summarized. CONCLUSIONS: 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. Additional research concerning the management of youth with depression in primary care is needed, including the usability, feasibility, and sustainability of guidelines and determination of the extent to which the guidelines actually improve outcomes of youth with depression.

Zuckerbrot RA, Cheung AH, Jensen PS, Stein RE, Laraque D, Anonymous00326. · Columbia University, Division of Child Psychiatry, Department of Psychiatry, 1051 Riverside Drive, Unit 78, New York, NY 10032, USA. · Pediatrics. · Pubmed #17974723 links to  free full text

Abstract: OBJECTIVES: To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This first part of the guidelines addresses identification, assessment, and initial management of adolescent depression in primary care settings. METHODS: 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. RESULTS: Guidelines were developed for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in primary care, including identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The identification, assessment, and initial management section of the guidelines includes recommendations for (1) identification of depression in youth at high risk, (2) systematic assessment procedures using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, (3) patient and family psychoeducation, (4) establishing relevant links in the community, and (5) the establishment of a safety plan. CONCLUSIONS: 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. Additional research that addresses the identification and initial management of depressed youth in primary care is needed, including empirical testing of these guidelines.

Cheung AH, Dewa CS, Levitt AJ, Zuckerbrot RA. · Sunnybrook Health Sciences Centre, Canada bHealth Systems Research and Consulting Unit, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Canada. · Curr Opin Pediatr. · Pubmed #18781118 No free full text.

Abstract: PURPOSE OF REVIEW: Depression is a common disorder that affects many youth. Although these youth are often managed in primary care, there is very little research or clinical guidance for primary care professionals to identify and manage depression in their pediatric patients. This review will examine the current evidence for the identification and management of pediatric depression in primary care. RECENT FINDINGS: Several recent primary studies and knowledge syntheses support the identification and management of adolescent depression in primary care with less evidence addressing depression in prepubertal patients. Research evidence from specialty care confirms the efficacy of antidepressants and psychotherapies in adolescent depression. However, there is the possible risk of rare but serious adverse events, as outlined in the Food and Drug Administration's warning, when using antidepressants to treat these youth. SUMMARY: Pediatric depression is often managed by primary care professionals. Several recent studies and reviews have been conducted to provide clinical guidance for the identification and management of depression in primary care.

Cheung AH, Emslie GJ, Mayes TL. · Department of Psychiatry, University of Toronto, Toronto, Ont. · CMAJ. · Pubmed #16415467 links to  free full text

Abstract: The dramatic increase over the past 10 years in the amount of available clinical research on the use of antidepressants to treat major depression in children and adolescents has substantially improved our knowledge of the safety and efficacy of these medications in the pediatric population. Many questions remain, however, that highlight the need to continue research in this patient population rather than relying on the extrapolation of data from trials involving adults. In this article, we review the current state of research into antidepressant therapy for major depression in children and adolescents. In addition, we discuss methodologic issues and clinical implications specific to the pediatric population.

Cheung AH, Emslie GJ, Mayes TL. · Department of Psychiatry, University of Toronto, Ontario, Canada. · J Child Psychol Psychiatry. · Pubmed #15972068 No free full text.

Abstract: BACKGROUND: Depression in children and adolescents is a cause of substantial morbidity and mortality in this population. It is a common disorder that affects 2% of children and up to 6% of adolescents. Although antidepressants are used frequently for the treatment of this disorder, there has been recent controversy about the efficacy and safety of these medications in this population. This review examined the available evidence from clinical trials of antidepressants in adolescents and children with depression. METHODS: Clinical trial data reviewed were obtained from published reports, including peer review journals and meeting abstracts, as well as unpublished data in the public domain. Clinical trials in this review included large RCTs of antidepressants in youth under the age of 19 with depression. Studies were identified in 2 stages: 1) all RCTs included in the 2004 FDA safety report were reviewed; and 2) to ensure that no additional studies not reported to the FDA were missed, MEDLINE and PSYCH Info were searched from inception until December 2004. A total of 8 published studies and 9 unpublished studies were identified and reviewed. RESULTS: Efficacy and safety results from each study are reviewed in detail. There are significant differences in remission and response rates between different antidepressants but also between placebo groups across studies. Adverse events are common in clinical trials involving children and adolescents with depression. Due to lack of access to full data sets, effect sizes could not be calculated. CONCLUSIONS: With the variability in trial methodology and the variation in the drug/placebo response rates within a single trial, clinicians need to be judicious in their interpretation of research data on pediatric antidepressant trials. Significant methodological issues may also have affected the efficacy and safety results from these clinical trials.

Cheung AH, Dewa CS. · Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, Sunnybrook Health Sciences Centre. · Healthc Policy. · Pubmed #19305706 links to  free full text

Abstract: BACKGROUND: Contrary to other developed countries where adolescent suicide rates have declined in the last decade, the rate in Canada has remained unchanged. Suicide is the second leading cause of death in Canadian adolescents and poses a serious public health concern. However, there is little epidemiological data examining the rates of suicidality or depression - two factors most closely associated with completed suicides. This study therefore examines the rates of depression and suicidality in adolescents aged 15-18. METHODS: Data from the Canadian Community Health Survey Cycle 1.2 on Mental Health and Well-being, a population-based survey conducted by Statistics Canada, were used to examine the rates of depression and suicidality in adolescents aged 15-18. Lifetime prevalence rates were calculated for depression and suicidality by region for males and females. Multivariate analyses were conducted to test the robustness of these results. RESULTS: The lifetime prevalence rates were 7.6% for depression and 13.5% for suicidality. There were significant gender differences for both: 4.3% of males and 11.1% of females had depression, and 8.8% of males and 18.4% of females had suicidality. After adjustment for age, sex and household income, the Maritimes had a lower rate of depression and British Columbia had a higher rate of suicidality relative to Ontario. Youth from low-income households had a higher risk of suicidality. INTERPRETATION: The findings suggest that depression and suicidality are common in adolescents and that females are more likely to be affected. The results also point to regional and socio-economic differences. Future research should examine differences that exist in mental health services provision and access. This will aid in the development of national, regional and local strategies to address the issue of depression and suicidality in Canadian adolescents.

Furimsky I, Cheung AH, Dewa CS, Zipursky RB. · Mental Health and Addictions Program, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada. · Contemp Clin Trials. · Pubmed #18721902 No free full text.

Abstract: Recruitment and retention of research participants is often the most labor-intensive and difficult component of clinical trials. Poor recruitment and retention frequently pose as a major barrier in the successful completion of clinical trials. In fact, many studies are prematurely terminated, or their findings questioned due to low recruitment and retention rates. The conduct of clinical trials involving youth with a first episode of mental illness comes with additional challenges in recruitment and retention including barriers associated with engagement and family involvement. To develop effective early interventions for first episode mental illness, it is necessary to develop strategies to enhance recruitment and retention in this patient population. This article presents the recruitment and retention challenges experienced in two clinical trials: one involving participants experiencing a first episode of depression and one involving participants experiencing a first episode psychosis. Challenges with recruitment and retention are identified and reviewed at both the patient level and clinician level. Strategies that were implemented to enhance recruitment and retention in these two studies are also discussed. Finally, ethical issues to consider when implementing these strategies are also highlighted.

Cheung AH, Zuckerbrot RA, Jensen PS, Stein RE, Laraque D, Anonymous00234. · Department of Psychiatry, University of Toronto, 33 Russell St, Third Floor Tower, Toronto, Ontario, M5S 2S1, Canada. · Pediatrics. · Pubmed #18166529 links to  free full text

Abstract: OBJECTIVE: Primary care clinics have become the "de facto" mental health clinics for teens with mental health problems such as depression; however, there is little guidance for primary care professionals who are faced with treating this population. This study surveyed experts on key management issues regarding adolescent depression in primary care where empirical literature was scant or absent. METHODS: Participants included experts from family medicine, pediatrics, nursing, psychology, and child psychiatry, identified through nonprobability sampling. The expert survey was developed on the basis of information from focus groups with patients, families, and professionals and from the research literature and included sections on early identification, assessment and diagnosis, initial management, treatment, and ongoing management. Means, standard deviations, and confidence intervals were calculated for each survey item. RESULTS: Seventy-eight of 81 experts agreed to participate (return rate of 96%). Fifty-three percent of the experts (n = 40) were primary care professionals. Experts endorsed routine surveillance for youth at high risk for depression, as well as the use of standardized measures as diagnostic aids. For treatment, "active monitoring" was deemed appropriate in mild depression with recent onset. Medication and psychotherapy were considered acceptable options for treatment of moderate depression without complicating factors such as comorbid illness. Fluoxetine was rated as the most appropriate antidepressant for use in this population. Finally, experts agreed that patients who are started on antidepressants should be followed within 2 weeks after initiation. CONCLUSIONS: Survey results support the identification and management of adolescent depression in the primary care setting and, in specific situations, referral and co-management with specialty mental health professionals. Even with the recent controversies around treatment, experts across primary care and specialty mental health alike agreed that active monitoring, pharmacotherapy with selective serotonin reuptake inhibitors, and psychotherapy can be appropriate under certain clinical circumstances when initiated within primary care settings.

Cheung AH, Dewa CS. · Departmentof Psychiatry, Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, University of Toronto, Ontario. · Can J Psychiatry. · Pubmed #17500303 No free full text.

Abstract: OBJECTIVES: Despite being recognized as a serious public health concern, suicidality among adolescents and young adults is frequently missed, and completed suicide remains the second leading cause of death for young Canadians. With such close links between depression, suicidality, and completed suicide, any intervention must address all 3 of these issues. However, to develop effective interventions, we must understand the types and rates of mental health service use among adolescents and young adults. This study examines service use rates in young Canadians with depression and suicidality and the influence of sex on the types of service provider chosen. METHODS: We used data from the Canadian Community Health Survey: Mental Health and Well-Being. Our sample included 619 individuals, aged 15 to 24 years, who screened positive for depression and suicidality in the past 12 months. We examined mental health service use rates in general and by provider type. RESULTS: Among adolescents aged 15 to 18 years with depression, 40% had not used any mental health services. This rate was higher for adolescents with suicidality at 50%. In young adults aged 19 to 24 with depression, 42% had not used any mental health services. Among young adults with suicidality, 48% had not accessed services. Female adolescents and young adults were more likely to receive services from nonspecialty mental health providers. CONCLUSIONS: In Canada, many adolescents and young adults with depression and suicidality do not receive mental health services. Further, there may be a preferential treatment of young men by mental health specialists. Further research is needed to understand the quality of care received by these young Canadians and the factors influencing service use.

Cheung AH, Levitt AJ, Szalai JP. · Department of Psychiatry, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Ontario. · Can J Psychiatry. · Pubmed #14733453 No free full text.

Abstract: OBJECTIVE: This study examines the relative impact of antidepressant side effects on adolescents with a history of major depression. METHODS: We used Q-sort methodology to capture the opinions of adolescents with a history of depression (n = 22), adults with a history of depression (n = 20), healthy adolescents (n = 20), and clinicians (n = 18) on the impact of 40 common antidepressant side effects. We asked subjects to force rank the side effects, judging each side effect on its relative impact on their daily lives. We also examined the impact of these side effects on health status and medication compliance. Primary analyses compared adolescents with depression with the other groups on their mean rankings for each of the 40 side effects. Secondary analyses included paired comparisons for ratings on health status and compliance. RESULTS: Although all groups ranked syncope and vomiting among the worst 5 side effects, significant differences were found between the groups on other side effects, such as anxiety, sleepiness, and hair loss. Based on the side effect with the most negative impact, adolescents with depression judged their own compliance (mean = 22%) to be higher than predicted by clinicians (mean = 11%). There were no significant differences between the groups on the mean rating of health status. CONCLUSIONS: Adolescents with depression, adults with depression, healthy adolescents, and clinicians agreed on the negative impact of 2 side effects: vomiting and syncope. Q-sort methodology provides valuable insight into the similarities and differences in opinion regarding the potential impact of side effects in patient groups.