Pediatric Reflections: Could it Be Depression?

Contributed by: Wendy J. Wallace, DO, FAAP “They are very moody but that is just adolescent mood swings” 

“I noticed my child losing weight so I thought I’d check in with the doctor”

“She used to participate in all sports, but now doesn’t leave her room” 

“He has been a straight A student, but now is getting Bs. That’s OK, right?”

There are common concerns voiced by parents to nursing staff while their child completes the Patient Health Questionnaire – 9 Questions (PHQ9), a self-report questionnaire designed for children 12 to 18 years of age.

The subtleties of depression in children and adolescents can be vague to both parents and providers. Yet all of these statements were heard at well visits from parents of children who later screened positive for depression by the PHQ9 (9 includes questions about suicidal ideation). Currently, treatment of depression isn’t addressed until a significant event occurs such as cutting, failing grades, anger outbursts, or a suicide attempt. Early intervention for depression in primary care will catch early signs and risk factors before these symptoms go too far.

Earlier this year I worked with CHOP psychologist Jason Lewis, PhD, and psychiatrist O’Nisha Lawrence, MD, to launch a clinical pathway for outpatient management of depression in children for ages 12 – 18 years. We shared perspectives on care to create a pathway of best practices, designed to assist providers in next steps after a patient screens positive for depression on the PHQ9. Beyond a diagnosis, the PHQ9—which should be given at each well visit—gives the child an opportunity to have a voice in how they are feeling at the time and also during weeks before the appointment. The pathway guides providers in managing mild pediatric depression in the office and how to give the child’s voice wings throughout treatment.

Giving a name to the child’s mood—depression—is sometimes the first time they have heard what is wrong with them. Even if they have heard about depression from friends or school programs, the child may not realize that is what they are experiencing. A full evaluation must be performed before determining next steps. This can be done at the time of the visit or a return visit for a full consult.

For mild depression, patients can be seen in the primary care office. The core treatment of mild depression is getting enough sleep, eating healthy, exercise, and talk therapy. School accommodations with reduced work load and guidance support are also helpful. Patients with more severe depression may be referred to a center for psychiatry or even hospitalized.

The pathway gives clear recommendations for each level of depression. It links providers to different resources, including study guides, articles/links to patient information, types of therapy, medication recommendations (If the provider feels comfortable prescribing), and referral/consult opportunities. Regardless of the level of depression, providers need to schedule recheck visits to ensure patients are receiving the care they need and to further build the doctor-patient partnership so the child does not feel alone in their depression.

Screening for depression in this age is critical to early intervention for mood disorders. If we don’t ask, they won’t tell. Primary care is the best place for these diagnoses to be made, and with the pathway, providers will have the confidence and knowledge to begin treatment or to make referrals for higher levels of care. Primary Care providers will be able to create more positive outcomes in the mental health treatment of their patients.