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NSG6999MonteroJ.-2.pptxevidence-based review of treatment for Adolescent depression
Jorge Montero
NSG6999 Graduate Project in Nursing
South University
Dr. Kristin Belderson
August 10, 2021
Depression
Depression is common and treatable, yet many people do not seek treatment. Dunphy, Winland-Brown, Porter, and Thomas (2019) describe depression or Major Depressive Disorder as a common condition that depict a wide variety of negative emotional states, ranging from sadness to loss of interest or pleasure in activities, to irritability and self-hate. It causes psychological pain, prompting for any solution that may bring relief. Depression presents some common characteristics such as sadness and anhedonia (loss of pleasure), that can be distinguished from ordinary changes in mood. Additionally, patients may have difficulty describing their pain and may make vague references to “hurting” or “feeling bad.” Thoughts of death or suicide are common.
Epidemiology
The population suffering from depression in the U.S. and European nations is estimated at about 20%, and approximately 9% in other developing countries. However, prevalence in those 65 years and older is significantly less compared with the younger population; except for those who are sick and/or in pain, in nursing homes, and in community-dwelling, or suffering from chronic medical conditions at 30 to 40% (Dunphy, Winland-Brown, Porter, & Thomas, 2019).
The COVID-19 pandemic, financial hardship, social isolation, heightened the risk for depression, particularly in the adolescent population (Schleider, et al., 2021).
Clinical presentation
Variations in the clinical presentation of depression can make it difficult to recognize.
Patients often present with somatic complaints and ambiguous symptoms of unexplained fatigue.
| Changes in appetite and weight Changes in sleep patterns Feelings of sadness Tearfulness Apathy, irritability Anger Anxiety Hyperactivity, low energy | Slowed thinking Emotional numbness Changes in grooming Interpersonal interactions Substance abuse Aggression Social withdrawal Decreased interest (Cheung & Sinyor, 2021) |
Diagnostic
DSM-5 requires five (or more) symptoms present during 2-week period.
Including depressed mood and/or anhedonia.
Diagnostic questions
Have you felt down or hopeless over the past few weeks?
Have you had little interest in doing things over the past few weeks?
Tools
Patient Health Questionnaire-9 (PHQ-9) with sensitivity (85%) and specificity (84%).
Quick Inventory of Depressive Symptomatology (QIDS-SR).
(Dunphy, Winland-Brown, Porter, & Thomas, 2019)
Management
The current guidelines for treatment of mild to moderate depression, recommends the use of antidepressants and/or psychotherapy, reserving combination therapy for more severe symptoms.
(Dunphy, Winland-Brown, Porter, & Thomas, 2019).
The Spirit of Inquiry Ignited
The management of adolescent depression is crucial in the primary care setting.
Primary care has readily available tools for diagnosing, treating, and managing it.
Available treatment guidelines should not replace clinical judgment but be a guide.
Possible side effects, withdrawal symptoms, and lack of evidence of the effectiveness of monotherapy unavoidably provokes intriguing questions about the real efficacy of the treatment. Does medication help? Does psychotherapy help? Or does the answer lay somewhere in a combination of psychotherapy and medication?
(Cheung, et al., 2018)
).
PICOT Question
Among nurse practitioners caring for adolescents diagnosed with depression in a primary care setting (P), does a nurse-led pharmacological therapy plan (I), compared to psychotherapy only (C), decrease depression symptoms (O) over a 1-year period (T)?
Searching for evidence Strategy
The search for evidence included a Boolean advance search of terms such as adolescent, depression, and treatment in databases such as the CINAHL Plus, PubMed, Cochrane Library, Dynamed, TRIP Medical, and South University Library. The search resulted in hundreds of studies.
Critical Appraisal of the Evidence
The studies went through a strict but objective selection process
They are level 1, systematic reviews or meta-analysis published with in the last five years.
Especial attention was focused on sample size, variables, analysis of data, results and the implication on clinical practice.
The studies focused on the comparative efficacy of antidepressants, psychotherapies, and their combination for the treatment of adolescents suffering from depression.
They revealed effectiveness and inadequacies of the current recommended treatments.
Synthesis
The systematic review of available data suggest that there is urgent need for additional research of evidence-based practice to treat depression in adolescents.
There is evidence a few successful treatments for adolescents, including psychotherapy and some medications (Weersing, Jeffreys, Do, Schwartz, & Bolano, 2017). Only SSRI medications have been approved by the FDA to be used in adolescents (Viswanathan, et al., 2020).
The outcomes agree that CBT is the leading intervention to treat adolescent depression, with no side effects when compared with pharmacotherapy (Viswanathan, et al., 2020), (Zhou, et al., 2020), (Weersing, Jeffreys, Do, Schwartz, & Bolano, 2017).
Adolescents suffering from depression should be treated with a combination of cognitive-behavioral therapy (CBT), and antidepressant medication for better results (Cheung, et al., 2018; Davey, et al., 2019; Foster, Mohler-Kuo, Tay, Hothorn, & Seibold, 2019; Viswanathan, et al., 2020; Zhou, et al., 2020).
Evidence Integration in Clinical practice
Recommendation:
To change the current depression treatment approach in adolescents to a combination of CBT and antidepressant treatment due to evidence reviewed points toward a higher chance of success than monotherapy when treating adolescents.
Key participants
1- Key stakeholders = All adolescent patients diagnosed with depression and their parents or guardians and their healthcare providers.
2- ARNPs, PAs, and physicians, will help champion project implementation.
3- Main barriers = Resistance to change and partial adherence by providers.
4- Modified Treatment Satisfaction Questionnaire for Medication (TSQM 14), to assess the patient satisfaction with the recommended combination therapy treatment.
Goals and evaluation
1- Measuring provider participation monthly.
2- Measuring patient response to the change.
3- Evaluating the implementation effect on the clinic.
Conclusion
• The COVID-19 pandemic affected adolescents to a higher degree.
• New recommendations urge that proper and reasonable treatment in primary care.
• All the research findings presented here suggest that a combination of CBT and antidepressants is the best option for the treatment of adolescent depression.
• There is a need for additional research on the subject.
• This project recommends a shift of the current treatment policy toward evidence-based combination therapy treatment.
• This change is not yet reflected in the current clinical practice in primary care, potentially missing its demonstrated benefits.
(Kapetanovic, Gurdal, Ander, & Sorbring, 2021; Cheung & Sinyor, 2021; Davey et al. 2019; Foster, Mohler-Kuo, Tay, Hothorn, & Seibold, 2019; Gunlicks-Stoessel, Klimes-Dougan, VanZomeren, & Ma, 2020; Viswanathan et al. 2020; Zhou et al. 2020; Hussain, Dubicka, & Wilkinson, 2018).
References
Cheung, A. H., Zuckerbrot, R. A., Jensen, P. S., Laraque, D., Stein, R. E., & GLAD-PC STEERING GROUP. (2018, March 01). Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics, 141, pp. 1-18. doi:10.1542/peds.2017-4082
Cheung, A., & Sinyor, M. (2021, February 28). Depression in children and adolescents in primary care. Pediatric Medicine, 4, pp. 1-10. doi:10.21037/pm-20-82
Davey, C. G., Chanen, A. M., Cotton, S. M., Hetrick, S. E., Kerr, M. J., Berk, M., . . . McGorry, P. (2019, July 29). The addition of fluoxetine to cognitive behavioural therapy for youth depression (YoDA-C): study protocol for a randomised control trial. The Lancet Psychiatry, 9, pp. 735-744. doi:10.1016/S2215-0366(19)30215-9
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care: Art and Science of Advanced Practice Nursing - An Interprofessional Approach (5th ed). Philadelphia, PA: F. A. Davis Company.
Foster, S., Mohler-Kuo, M., Tay, L., Hothorn, T., & Seibold, H. (2019, May). Estimating patient-specific treatment advantages in the ‘Treatment for Adolescents with Depression Study’. Journal of Psychiatric Research, 112, pp. 61-70. doi:10.1016/j.jpsychires.2019.02.021
Kapetanovic, S., Gurdal, S., Ander, B., & Sorbring, E. (2021, January 15). Reported changes in adolescent psychosocial functioning during the COVID-19 outbreak. Adolescents, 1, pp. 10-20. doi:10.3390/adolescents1010002
Schleider, J. L., Mullarkey, M. C., Fox, K., Dobias, M. L., Shroff, A., Hart, E., & Roulston, C. A. (2021, April 08). Single-session interventions for adolescent depression in the context of COVID-19: A nationwide randomized-controlled trial. PsyArXiv, pp. 1-29. doi:10.31234/osf.io/ved4p
Viswanathan, M., Kennedy, S. M., McKeeman, J., Christian, R., Coker-Schwimmer, M., Middleton, J. C., . . . Forman-Hoffman, V. (2020, April 01). Treatment of depression in children and adolescents: A systematic review. Comparative Effectiveness Review No. 224, pp. 1-1145. doi:10.23970/AHRQEPCCER224
Weersing, V. R., Jeffreys, M., Do, M.-C. T., Schwartz, K. T., & Bolano, C. (2017, January 01). Evidence- Base Update of Psychosocial Treatments for Child and Adolescent Depression. Journal of clinical child and adolescent psychology, 46, pp. 11-43. doi:10.1080/15374416.2016.1220310
Zhou, X., Teng, T., Zhang, Y., Giovane, C. D., Furukawa, T. A., Weisz, J. R., . . . Xie, P. (2020, July 01). Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis. Lancet Psychiatry, 7, pp. 581-601. doi:10.1016/S2215-0366(20)30137-1
