- Email: [email protected]
Abstract Thinking: Pediatric Primary Care Providers and Depression in Community Settings
HERE
In This Issue Volume 47, Number 9: September 2008
This issue of the Journal tackles real-world questions regarding mental health care for youths and families exposed to unique environments and hardships. The following pages include studies about deployment of empirically based treatments in Bosnia and Herzegovina, assessment of early life risk factors and developmental trajectories after a massive Canadian ice storm, and the misuse of prescription substances by youths in all walks of life. High-quality research that responds to the needs of diverse communities is essential to ensure that the tools used in the mental health field are acceptable, effective, and relevant. Sustained Effects of School-Based Cognitive-Behavioral Therapy on Adolescent Anxiety
Long-term results of empirically informed interventions for youths and families with mental health problems are few and far between. Bernstein et al. (p. 1039) provide information about the long-term impact of cognitivebehavioral therapy for youths identified and treated for anxiety in school settings. Parents and clinicians reported an improvement in youth anxiety symptoms and overall functioning that remained significant 12 months after the intervention was completed, despite a relatively small control group. These results are encouraging and suggest that relatively brief interventions, performed in community settings, may have enduring effects on functioning. Benefits When Trauma Intervention Is Added to Established School-Based Intervention
Layne et al. (p. 1048) implemented trauma and grief component therapy for adolescents (TGCT), a modulized, individualized therapy with group and individual components, to more than 100 students in 33 secondary schools in Bosnia and Herzegovina. This comparative effectiveness trial sought to reveal additional benefit of TGCT when added to a preexisting school-based program that included classroom-based posttraumatic stress disorder interventions and widespread dissemination of psychoeducational materials to families. Symptoms did decrease in both the TGCT group and the control group. The group who received TGCT had added benefits in target symptom and overall improvement and was less likely to experience overall decline throughout the follow-up period. These findings provide evidence that implementing a modulized, empirically informed intervention in schools whose students are exposed to high levels of trauma is feasible and can improve outcomes for youths and families even in the presence of systemic classroom-based interventions. Differential Effects of Prenatal Stress on Linguistic Outcomes
Laplante et al. (p. 1063) prospectively examined the effects of prenatal exposure to a natural disaster on linguistic and intellectual abilities at 52 years of age. Women in the study lost electricity for an average of 15 days after a massive ice storm struck Canada. The study found that objective, but not subjective, exposure to stressful life events has a negative impact on verbal and language skills. To produce informative results, these researchers needed to respond quickly and swiftly to a natural event and work closely with a displaced community. An interesting curvilinear relation between prenatal exposure to stressful life events and development was noted, in which youths exposed to moderate, but not high or low, levels of stressful life events actually had better linguistic performance. These findings confirm the concept that prenatal stress affects development, but suggest that the relation is complex and not linear. A better understanding of the group that had better linguistic skills and moderate levels of stress may help inform future preventive interventions that could be used in the wake of natural or manmade disasters.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 47:9, SEPTEMBER 2008
WWW.JAACAP.COM
975
THERE
Abstract Thinking Pediatric Primary Care Providers and Depression in Community Settings
Pediatric primary care providers are well placed to provide early identification and treatment of depression but often lack sufficient time, training, and/or referral sources to feel comfortable evaluating and treating child and adolescent depressive disorders. Pediatric providers frequently encounter youths who have symptoms of or are at risk for depression. For example, families often present to their pediatrician with concerns about infant and early childhood sleep problems or adolescent complaints of fatigue, both of which, in addition to being symptoms of depression, have been identified as risk factors for developing emotional disorders.1,2 Unfortunately, without proper tools and support, it may be more feasible to recommend a sleep aid or order blood tests than to diagnose an underlying and often treatable mental health disorder. The typical duration of office visits is certainly a factor, and although the potential for divergent parent and child symptoms reports is not unique to mental health,3 the amount of time required to perform a traditional psychiatric interview with both a child and parent would be difficult to find in a busy pediatric practice. To help guide pediatric providers, a set of evidence-based guidelines for the identification4 and management5 of adolescent depression in pediatric primary care has been published, and a toolkit to facilitate systematic implementation is available online at www.glad-pc.org. These guidelines were the result of an iterative process involving literature reviews, provider focus groups, surveys, and a consensus conference whose participants included both mental health and physical health providers. The majority of participants were primary care providers with an average of 20 years` experience. Results of the expert survey have been published and revealed a high amount of convergence of opinions regarding the appropriateness of asking general questions to identify depression in high-risk youths6 despite the fact that the use of screening tools has been shown to be superior.7 The identification guidelines recommend that pediatricians screen for depression in high-risk youths and in those who present with emotional problems as their chief complaint and form linkages with mental health resources in the community. In youths with depression, psychoeducation should be provided and a treatment plan with target goals created. The guidelines also highlight the importance of safety planning. The monitoring guidelines suggest active monitoring for youths with mild depression and the use of evidence-based treatment such as selective serotonin reuptake inhibitors and cognitive-behavioral therapy and/or consultation with a mental health professional when youths do not respond to active monitoring or have more severe forms of depression. Those pediatric providers who do choose to prescribe selective serotonin reuptake inhibitors should monitor for the development of adverse events. The expert panel recognized that pediatric providers have different levels of interest (and/or expertise?) and support for providing pharmacological treatment, but highlight that the consensus panel was designed as a guide for all providers, regardless of whether they tend to treat or refer youths with depressive disorders. Abigail B. Schlesinger, M.D. University of Pittsburg [email protected] DOI: 10.1097/CHI.0b013e3181eedb0
Disclosure: The author reports no conflicts of interest. REFERENCES *Selected abstracts from the referenced articles below are interspersed throughout this issue. 1. ter Wolbeek M, van Doornen LJ, Kavelaars A, Heijnen CJ. Predictors of persistent and new-onset fatigue in adolescent girls. Pediatrics. 2008;121:e449Ye457. 2. Gregory AM, Van der Ende J, Willis TA. Parent-reported sleep problems during development and self-reported anxiety/depression, attention problems, and aggressive behavior later in life. Arch Pediatr Adolesc Med. 2008;162:330Y335. 3. Johnson SB, Wang C. Why do adolescents say they are less healthy than their parents think they are? The importance of mental health varies by social class in a nationally representative sample. Pediatrics. 2008;121:e307Ye313. 4. Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for adolescent depression in primary care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 2007;120;e1299Ye1312. 5. Cheung AH, Jensen PS, Zuckerbrot RA, et al. Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120:e1313Y1326. 6. Cheung AH, Zuckerbrot RA, Jensen PS, Stein RE, Laraque D. Expert survey for the management of adolescent depression in primary care. Pediatrics. 2008;121:e101Ye107. 7. Zuckerbrot RA, Jensen PS. Improving recognition of adolescent depression in pediatric primary care. Arch Pediatr Adolesc Med. 2006;160:694Y704.
976
WWW.JAACAP.COM
J. AM . AC AD. C HILD ADOLESC . PSYCH IATRY, 47:9, SE PTE MBER 2008
In This Issue Volume 47, Number 9: September 2008
This issue of the Journal tackles real-world questions regarding mental health care for youths and families exposed to unique environments and hardships. The following pages include studies about deployment of empirically based treatments in Bosnia and Herzegovina, assessment of early life risk factors and developmental trajectories after a massive Canadian ice storm, and the misuse of prescription substances by youths in all walks of life. High-quality research that responds to the needs of diverse communities is essential to ensure that the tools used in the mental health field are acceptable, effective, and relevant. Sustained Effects of School-Based Cognitive-Behavioral Therapy on Adolescent Anxiety
Long-term results of empirically informed interventions for youths and families with mental health problems are few and far between. Bernstein et al. (p. 1039) provide information about the long-term impact of cognitivebehavioral therapy for youths identified and treated for anxiety in school settings. Parents and clinicians reported an improvement in youth anxiety symptoms and overall functioning that remained significant 12 months after the intervention was completed, despite a relatively small control group. These results are encouraging and suggest that relatively brief interventions, performed in community settings, may have enduring effects on functioning. Benefits When Trauma Intervention Is Added to Established School-Based Intervention
Layne et al. (p. 1048) implemented trauma and grief component therapy for adolescents (TGCT), a modulized, individualized therapy with group and individual components, to more than 100 students in 33 secondary schools in Bosnia and Herzegovina. This comparative effectiveness trial sought to reveal additional benefit of TGCT when added to a preexisting school-based program that included classroom-based posttraumatic stress disorder interventions and widespread dissemination of psychoeducational materials to families. Symptoms did decrease in both the TGCT group and the control group. The group who received TGCT had added benefits in target symptom and overall improvement and was less likely to experience overall decline throughout the follow-up period. These findings provide evidence that implementing a modulized, empirically informed intervention in schools whose students are exposed to high levels of trauma is feasible and can improve outcomes for youths and families even in the presence of systemic classroom-based interventions. Differential Effects of Prenatal Stress on Linguistic Outcomes
Laplante et al. (p. 1063) prospectively examined the effects of prenatal exposure to a natural disaster on linguistic and intellectual abilities at 52 years of age. Women in the study lost electricity for an average of 15 days after a massive ice storm struck Canada. The study found that objective, but not subjective, exposure to stressful life events has a negative impact on verbal and language skills. To produce informative results, these researchers needed to respond quickly and swiftly to a natural event and work closely with a displaced community. An interesting curvilinear relation between prenatal exposure to stressful life events and development was noted, in which youths exposed to moderate, but not high or low, levels of stressful life events actually had better linguistic performance. These findings confirm the concept that prenatal stress affects development, but suggest that the relation is complex and not linear. A better understanding of the group that had better linguistic skills and moderate levels of stress may help inform future preventive interventions that could be used in the wake of natural or manmade disasters.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 47:9, SEPTEMBER 2008
WWW.JAACAP.COM
975
THERE
Abstract Thinking Pediatric Primary Care Providers and Depression in Community Settings
Pediatric primary care providers are well placed to provide early identification and treatment of depression but often lack sufficient time, training, and/or referral sources to feel comfortable evaluating and treating child and adolescent depressive disorders. Pediatric providers frequently encounter youths who have symptoms of or are at risk for depression. For example, families often present to their pediatrician with concerns about infant and early childhood sleep problems or adolescent complaints of fatigue, both of which, in addition to being symptoms of depression, have been identified as risk factors for developing emotional disorders.1,2 Unfortunately, without proper tools and support, it may be more feasible to recommend a sleep aid or order blood tests than to diagnose an underlying and often treatable mental health disorder. The typical duration of office visits is certainly a factor, and although the potential for divergent parent and child symptoms reports is not unique to mental health,3 the amount of time required to perform a traditional psychiatric interview with both a child and parent would be difficult to find in a busy pediatric practice. To help guide pediatric providers, a set of evidence-based guidelines for the identification4 and management5 of adolescent depression in pediatric primary care has been published, and a toolkit to facilitate systematic implementation is available online at www.glad-pc.org. These guidelines were the result of an iterative process involving literature reviews, provider focus groups, surveys, and a consensus conference whose participants included both mental health and physical health providers. The majority of participants were primary care providers with an average of 20 years` experience. Results of the expert survey have been published and revealed a high amount of convergence of opinions regarding the appropriateness of asking general questions to identify depression in high-risk youths6 despite the fact that the use of screening tools has been shown to be superior.7 The identification guidelines recommend that pediatricians screen for depression in high-risk youths and in those who present with emotional problems as their chief complaint and form linkages with mental health resources in the community. In youths with depression, psychoeducation should be provided and a treatment plan with target goals created. The guidelines also highlight the importance of safety planning. The monitoring guidelines suggest active monitoring for youths with mild depression and the use of evidence-based treatment such as selective serotonin reuptake inhibitors and cognitive-behavioral therapy and/or consultation with a mental health professional when youths do not respond to active monitoring or have more severe forms of depression. Those pediatric providers who do choose to prescribe selective serotonin reuptake inhibitors should monitor for the development of adverse events. The expert panel recognized that pediatric providers have different levels of interest (and/or expertise?) and support for providing pharmacological treatment, but highlight that the consensus panel was designed as a guide for all providers, regardless of whether they tend to treat or refer youths with depressive disorders. Abigail B. Schlesinger, M.D. University of Pittsburg [email protected] DOI: 10.1097/CHI.0b013e3181eedb0
Disclosure: The author reports no conflicts of interest. REFERENCES *Selected abstracts from the referenced articles below are interspersed throughout this issue. 1. ter Wolbeek M, van Doornen LJ, Kavelaars A, Heijnen CJ. Predictors of persistent and new-onset fatigue in adolescent girls. Pediatrics. 2008;121:e449Ye457. 2. Gregory AM, Van der Ende J, Willis TA. Parent-reported sleep problems during development and self-reported anxiety/depression, attention problems, and aggressive behavior later in life. Arch Pediatr Adolesc Med. 2008;162:330Y335. 3. Johnson SB, Wang C. Why do adolescents say they are less healthy than their parents think they are? The importance of mental health varies by social class in a nationally representative sample. Pediatrics. 2008;121:e307Ye313. 4. Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for adolescent depression in primary care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 2007;120;e1299Ye1312. 5. Cheung AH, Jensen PS, Zuckerbrot RA, et al. Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120:e1313Y1326. 6. Cheung AH, Zuckerbrot RA, Jensen PS, Stein RE, Laraque D. Expert survey for the management of adolescent depression in primary care. Pediatrics. 2008;121:e101Ye107. 7. Zuckerbrot RA, Jensen PS. Improving recognition of adolescent depression in pediatric primary care. Arch Pediatr Adolesc Med. 2006;160:694Y704.
976
WWW.JAACAP.COM
J. AM . AC AD. C HILD ADOLESC . PSYCH IATRY, 47:9, SE PTE MBER 2008