Identification of Major Depressive Disorder in Adolescents

One in every 4 to 5 youths will suffer a debilitating mental health disorder by the time they are 18 years old.

Mood and anxiety disorders make up a large proportion of these mental health conditions with over 40% of adolescents having more than one disorder.¹ Several mood disorders such as major depressive disorder (MDD), dysthymic disorder, bipolar, substance induced, mood disorder due to medical condition, premenstrual dysmorphic disorder, and disruptive mood regulation disorder afflict adolescents.²

MDD is the most prevalent mental health disorder in adolescents and is the leading cause of disability among young people ages 10-24 years worldwide. 3-5 MDD is characterized as having 1 or more major depressive episodes (MDE) that last a minimum of 2 weeks. Symptoms may include episodes of disruptive mood and irritability instead of only a sad mood, and can last weeks, months, or potentially years.⁶ These episodes are often recurrent. Also, increasing number of events indicates risk for future depression. Over 40% of children and teens with MDD will experience a second episode within 2 years, with approximately 75% exhibiting symptoms within 5 years, and nearly 100% during adulthood.⁴

MDD Prevalence and Risk

According to the 2010 National Comorbidity Study-Adolescent Supplement (NCA-S) lifetime MDD or dysthymia was reported as 11.7%, see Table 1.⁷ More recent data collected from the National Survey on Drug Use and Health (NSDUH) shows that in 2016, 12.8% of adolescents reported having a MDE in the last 12 months. The prevalence of having a MDE was similar to 2015, but higher than reported percentages yearly from 2004-2014. In 2016, females were three times as likely as males to report having a MDE, 19.4% compared to 6.4%. Continuing, white adolescents had the highest percentage compared to Hispanics and Blacks, see Table 2.⁸ Gender differences in depression develop during early adolescence; adolescent girls experience more peer stress than boys and are more likely to become depressed especially post-puberty.⁹ Adolescents may be prone to depression because of a combination of genetic risk factors and environmental exposures. Familial transmission, cognitive risk factors, lack of confidence, and negative life events such as low socioeconomic status, physical abuse, sexual abuse, and peer stress all are factors that contribute to MDD.6,9

Significance for MDD Screening in Primary Care

MDD is a cause of significant morbidity and mortality in adolescents. Physical illness, substance abuse, poor relationships, impaired school performance, high-risk sexual behavior, and suicide are examples.¹ Over 19% of adolescents age 13-17.9 years with MDD have suicide attempts. Suicide is the third leading cause of death in 10-19 year olds. Adolescents who exhibit signs of depression are often overlooked; many times any difference in behavior may be considered pubertal changes.³

Few adolescents with depressive disorders seek a specialist, however many go to their primary care provider (PCP) for various reasons. Therefore, PCPs, both family and pediatric, play a significant role in potentially identifying depression and implementing early intervention. They are likely the first point of contact for adolescents and families. PCPs can facilitate with identification and management of depression as well as initiate referral to mental health specialists.¹⁰

However, there remains a lack of screening and early intervention in primary care settings.¹⁰ About 75% of teenagers visit a general practitioner each year with approximately 20% having a concurrent depressive episode which often goes unrecognized by the provider.¹¹ Nationwide studies have shown that less than half of adolescents with MDD receive treatment.¹⁰ Low rate of mental health treatment stems from multiple factors including lack of comfort in diagnosing and managing these issues.¹² There is little knowledge of resources for intervention, and very few PCPs are able to provide mental health counseling.¹³ Knowledge of accurate screening tools can assist clinicians in identifying MDD in adolescents.⁵

Guidelines

Recommendations for screening for MDD in adolescents and children were updated by the U.S Preventative Services Task Force (USPSTF) in February, 2016. These new guidelines closely parallel the recommendations for adults. The USPSTF recommends screening all adolescents age 12-18 years for MDD. Screening should be performed routinely by all PCPs and protocols should be put in place to ensure adequate treatment and follow-up care. Appropriate systems include not only having a method for screening, but also having the staff available to ensure the adolescent is properly diagnosed and referred to a mental health specialist if needed. It is also important to mention current evidence is lacking for the benefits and harms of screening MDD in children 11 years and younger, therefore this age group should not be screened.⁶

Screening for MDD has a moderate net benefit and there is sufficient evidence that screening tests can correctly identify MDD in adolescents. However, studies that directly evaluate whether screening leads to improved health outcomes have not been identified. The USPSTF concludes that treatment of MDD found through screening is associated with reduction in depression symptoms, severity, and global functioning scores. Removed from the updated guidelines is the use of specific pharmacological therapies for adolescents. When adolescents are monitored closely the concerns for harms associated with pharmacotherapy are diminished.⁶

Interval and Opportunities for Screening

The USPSTF mentions that while an ideal interval for screening is not evident, the process should be individualized by identifying teenagers at high risk and considering how many screening opportunities have been offered. Repeated screening may be most beneficial to those with risk factors for MDD and opportunistic screening for those who infrequently visit the provider can be useful.⁶ The American Academy of Pediatrics (AAP) Task Force on Mental Health proposes that screening take place in a variety of settings. These include health maintenance visits, acute visits, and whenever a circumstance occurs, such as decreased school performance.¹⁴ Adolescents with depression are also more likely to present with somatic symptoms such as headache, stomach aches, and musculoskeletal pain and should be considered for evaluation.¹⁰ The AAP’s Bright Futures program recommends that adolescents be screened annually at 11 years for emotional and behavioral problems including depression.¹⁵

Screening Tools

A recent systematic review completed by USPSTF on accuracy of screening tests did not yield any new instruments since their 2009 review. Five quality studies were acknowledged with two of the most reliable tools being the Patient Health Questionnaire for Adolescents (PHQ-A) and the Beck Depression Inventory (BDI). While the PHQ-A and BDI were deemed most reliable, they are lengthy and the BDI requires provider training.^10,15 Other instruments they identified include the Center for Epidemiologic Studies Depression Scale (CES-D) and the Clinical Interview Schedule-Revised Questionnaire (CIS-R). The CES-D had inconsistent results for accuracy based on sex, see Table 3.¹⁰

While not included in the USPSTF review, the Patient Health Questionnaire-2 Item (PHQ-2) and the Patient Health Questionaire-9 Item (PHQ-9) have demonstrated good diagnostic validity for adolescents. A two questions tool, the PHQ-2, has sufficient sensitivity and specificity to initially identify those adolescents who need further screening for MDD. The PHQ-9 can then be used for further evaluation. Both tools are brief and easily accessible for the busy provider.^16,17 The AAP also summarizes depression screening tools for adolescents that are deemed acceptable with sensitivity and specificity levels of at least 70%, see Table 3.¹⁵ Ideal screening tools should be easily understood, brief, freely accessible, and have strong performance characteristics.¹⁷

Discussion

Studies have shown that adequate provider training on adolescent depression and screening techniques can increase the confidence of providers and the frequency of screening. Evidence reveals the use of training and clinical depression toolkits, which contain treatment algorithms, screening tools, treatment options, and referral criteria, were successful in addressing barriers to screening.^12,18 AAP has a freely accessible toolkit with valuable information on how to screen and implement mental health care.¹⁵

PCPs need to be aware of risk factors for MDD in adolescence and promote early intervention. A variety of valid screening tools for adolescents have been discussed and are available for comparison to help choose the right tool for one’s own practice. Toolkits are accessible to guide screening and referral. MDD is a serious problem afflicting the adolescent population and it is the duty of all PCPs to become knowledgeable about how to properly screen and manage these patients.^6,10,15

References

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