Depression: Zuckerbrot RA

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methodologies, guidelines were developed in 5 phases as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) revision and iteration among members of the steering committee.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 A, Ewigman B, Zuckerbrot RA, Jensen PS. · University of Toronto, Toronto, Ontario, Canada. · J Fam Pract. · Pubmed #19442389 No free full text.

This publication has no abstract.

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.

Zuckerbrot RA, Jensen PS. · Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University and Center for the Advancement of Children's Mental Health, Columbia University/New York State Psychiatric Institute, New York, USA. · Arch Pediatr Adolesc Med. · Pubmed #16818834 links to  free full text

Abstract: OBJECTIVE: To address the following questions: (1) What evidence (ie, psychometric data collected in pediatric primary care, patient outcome data) exists for the various methods used to identify adolescent depression in primary care? and (2) What identification practices are currently in use? DATA SOURCES: We systematically searched MEDLINE for English-language articles using specific search terms and examined relevant titles, abstracts, and articles. STUDY SELECTION: We reviewed 1743 MEDLINE abstracts. Seventy-four articles were pulled for examination, with 30 articles meeting full criteria. DATA EXTRACTION: Five studies had adequate psychometric data on various adolescent depression identification methods in primary care. Only 1 compared the diagnostic accuracy of physicians trained to ask depression questions vs physicians trained in the use of a diagnostic aid. Six studies reported on current practice. Evidence regarding sensitivity, specificity, positive predictive value, and negative predictive value was sought for question 1. Frequency of screening was sought for question 2. DATA SYNTHESIS: Review of these articles found that few health care professionals use systematic depression identification methods, despite some growing evidence for their validity, feasibility, and possible efficacy. CONCLUSION: Available evidence indicates that primary care professionals would improve their rates of depression diagnosis through training, but even more so by using adolescent symptom rating scales.

Cheung A, Ewigman B, Zuckerbrot RA, Jensen PS. · University of Toronto, Ontario, Canada. · J Fam Pract. · Pubmed #19358796 No free full text.

This publication has no abstract.

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.

Zuckerbrot RA. · Columbia University/New York State Psychiatric Institute, New York, NY, USA. · Evid Based Ment Health. · Pubmed #17652566 No free full text.

This publication has no abstract.

Zuckerbrot RA, Maxon L, Pagar D, Davies M, Fisher PW, Shaffer D. · Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University, New York, New York, USA. · Pediatrics. · Pubmed #17200276 links to  free full text

Abstract: OBJECTIVE: Despite available depression treatments, only one fourth to one third of depressed adolescents are receiving care. The problem of underdiagnosis and underreferral might be redressed if assessment of suicidality and depression became a more formal part of routine pediatric care. Our purpose for this study was to explore the feasibility and acceptability of implementing adolescent depression screening into clinical practice. METHODS: In this study we implemented a 2-stage adolescent identification protocol, a first-stage pen-and-paper screen and a second-stage computerized assessment, into a busy primary care pediatric practice. Providers tracked the number of eligible patients screened at both health maintenance and urgent care visits and provided survey responses regarding the burden that screening placed on the practice and the effect on patient/parent-provider relationships. RESULTS: Seventy-nine percent of adolescent patients presenting for health maintenance visits were screened, as were the majority of patients presenting for any type of visit. The average completion time for the paper screen was 4.6 minutes. Providers perceived parents and patients as expressing more satisfaction than dissatisfaction with the screening procedures and that the increased time burden could be handled. All providers wished to continue using the paper screen at the conclusion of the protocol. CONCLUSIONS: Instituting universal systematic depression screening in a practice with a standardized screening instrument met with little resistance by patients and parents and was well perceived and accepted by providers.