Management of Adolescent Depression in the Primary Care


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University of Massachusetts Amherst
[email protected] Amherst
Doctor of Nursing Practice (DNP) Projects

College of Nursing

2016
Management of Adolescent Depression in the Primary Care Setting: An Educational Program for Providers
Kelly Clow
University of Massachusetts Amherst

Follow this and additional works at: https://scholarworks.umass.edu/nursing_dnp_capstone Part of the Child Psychology Commons, Family Practice Nursing Commons, and the Mental
Disorders Commons
Clow, Kelly, "Management of Adolescent Depression in the Primary Care Setting: An Educational Program for Providers" (2016). Doctor of Nursing Practice (DNP) Projects. 62. Retrieved from https://scholarworks.umass.edu/nursing_dnp_capstone/62
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Running Head: MANAGEMENT OF ADOLESCENT DEPRESSION

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Management of Adolescent Depression in the Primary Care Setting An Educational Program for Providers Kelly Clow UMass College of Nursing

Capstone Chair: Capstone Committee Member: Capstone Mentor: Date of Submission:

Pamela Aselton, PhD, FNP Emma Dundon, PhD, CPNP Gretchen Kelley, MD 04/30/16

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Table of Contents Abstract ................................................................................................................................3 Introduction and Background ..............................................................................................4 Problem Statement ...............................................................................................................7 Review of the Literature ......................................................................................................7 Theoretical Framework ......................................................................................................29 Project Design and Methods ..............................................................................................33
Settings and Resources ................................................................................................35 Facilitators and barriers................................................................................................36 Goals and Objectives ...................................................................................................37 Human Subjects Protection.........................................................................................37 Results ..........................................................................................................................38 Discussion ....................................................................................................................42 Conclusion .........................................................................................................................45 References ..........................................................................................................................47 Appendix ............................................................................................................................57

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Abstract Background: The prevalence of adolescent depression is estimated at 15-20% in the general population and often undertreated. The primary care provider is in a prime position to identify and treat depression in this age group. However, many providers feel uncomfortable with treating and managing depression in adolescents, due to a lack of education or experience. Purpose: The focus of this quality improvement project was to educate primary care providers on the current recommendations for the management of adolescent depression and provide an education sheet for both the medical and non-medical treatment of adolescent depression. An educational intervention was presented to providers at a physician-owned private practice family clinic in Massachusetts. Pre-test and post-test scores were compared to determine the change in knowledge and confidence levels. Results: Eight providers attended the education presentation and completed the pre-test and seven of these providers also completed the post-test. The results indicated an improvement in provider’s level of confidence of understanding ways to manage adolescent depression (p=.030) and in being familiar with evidenced based management options (p=.045). There was no change in the provider’s confidence in ability to manage adolescent depression or discuss a variety of treatment options or in the provider’s understanding of the CBT model following the education intervention. Discussion: Due to limited education regarding mental health issues in primary care programs, offering supplemental education may help to meet this need as specialized providers are limited. The findings suggest that a longer term education intervention may be useful in increasing knowledge and confidence level of providers related to the management of adolescent depression in the primary care setting.
Keywords: Adolescent depression, primary care, depression treatment, depression management

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Introduction and Background Adolescent depression is a significant health problem among adolescents and has become a major public health concern today. Adolescent depression can interfere with role functioning and is associated with impaired social/academic functioning and recurrence in adulthood (Kramer et al., 2013; Prager, 2009). Suicide is one of the leading causes of death among adolescents and is often correlated with depression (Asarnow et al., 2005; Richardson & Katzenellenbogen, 2005; Young, Miller, & Khan, 2010). Depression is increasingly affecting the adolescent population with lifetime prevalence rates estimated at 15-20% (Asarnow et al., 2005; Cheung, Kozloff, & Sacks, 2013; Richardson & Katzenellenbogen, 2005). Adult depression often begins in the adolescent years, which strengthens the importance of recognizing, treating and managing symptoms of depression in the adolescent population (Asarnow et al., 2005). Studies suggest that in the absence of a diagnosed depressive disorder, depressive symptoms in the adolescent years increase the chance of development of major depression later in life. Maslow, Dunlap and Chung (2015) report an estimate of 75% of depressed adolescents do not receiving treatment. The primary care setting is a major point of health care contact for many adolescents making it an ideal setting for detecting and treating depression with the goal of improving overall health. Unfortunately, the identification of depression in the adolescent is often overlooked and untreated in the primary care setting (Fallucco, Seago, Cuffe, Kaemer, & Wysocki, 2015; Kramer & Garralda, 1998). According to Kelleher, Campo, and Gardner (2006), adolescents with mental health disorders tend to use the primary care setting at higher rates than those without these disorders; therefore, the primary care provider is in a position to initiate, manage and coordinate care of adolescents with depression. The focus of improvement on the quality of

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this care has been highlighted by historical failure to accurately diagnose and treat adolescents, in addition to limited supply of child mental health specialists.
Asarnow et al. (2005) identifies a number of factors that potentially play a role in depression going undetected. These factors include: competing demands in a busy practice, distinguishing the difference between normal adolescent behavior and clinically depressive symptoms in a short visit, and the difficulty an adolescent has in expressing themselves. These factors, coupled with the fact that most primary care visits focus on a medical condition rather than psychiatric complaints may lead to depression being overlooked in this population (Asarnow et al., 2005). Cheung et al. (2013) and Prado, Pantin and Estrada (2015) identify barriers to the management of adolescent depression including limitations in time, reimbursement, training and access to mental health services. Richardson et al. (2007) conducted a focus group with 35 providers and found three common themes that influenced provider’s decisions regarding treatment for depression including lack of availability of mental health resources in the community, feeling responsible for helping based on long standing relationships with patients and families, and patient and family beliefs and preferences regarding treatment. Many primary care visits are short and if multiple issues are brought up they all may not be adequately addressed in one visit. This increases the potential for depression to go unrecognized and untreated.
In the past, psychiatrist or providers who had specialized training in psychiatry/mental health primarily managed psychiatric illness. More recently primary care providers are being relied upon to not only diagnose and manage medical illness, but also to assess and manage psychiatric conditions. Unfortunately, the option to see a mental health professional is not always feasible. There is a deficit in the availability of therapists, psychologists and psychiatrists in

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many areas; therefore, the primary care provider is often taking on the role of treating depression and other mental health issues (Fleury, Imboua, Aube, Farland, & Lambert, 2012; Kelleher et al., 2006).
The expectation of the primary care provider to provide comprehensive mental and physical health service presents challenges. One challenge is that the education of the primary care provider may not have included enough content in the care of psychiatric conditions and many providers feel unprepared to provide high quality care for mental health disorders (Fleury et al., 2012; Gray & Dihigo, 2015). A study of pediatricians and family providers found that 58% reported prescribing selective serotonin reuptake inhibitors (SSRI), and only 8% reported adequate training for this (Rushton, Clark & Freed, 2000). According to Whitebird et al. (2013) depression is the most common mental health condition to be treated in the primary care setting (across all ages). In a busy primary care practice there may not be enough time to adequately assess mental health and psychosocial concerns (Gray & Dihigo, 2015).
The importance of increasing the recognition and treatment of adolescent depression is highlighted in the national initiative Healthy People 2020 (Healthy People 2020, 2014). Maslow, Dunlap and Chung (2015) identify the importance of primary care providers to not only to continue prescribing SSRI medication but also to improve their knowledge and comfort in using antidepressants to treat adolescent depression. Families often report a trusted relationship with the primary care provider and prefer to speak with the provider regarding mental health issues during regular healthcare visits rather than go to an outside mental health provider (Kelleher et al., 2006). Evidenced based practice guidelines have identified various interventions, which can lead to management of symptoms and clinical improvement in depressed adolescents.

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Problem Statement Depression is often unidentified in the adolescent population despite it being common in the pediatric primary care setting. Reeves and Riddle (2014) identify depression as ranking higher than common medical problems such as asthma or anemia. Untreated depression can lead to adverse outcomes in the adult years including lower educational attainment and poorer physical health (Maslow, Dunlap, & Chung, 2015). Adolescents with depression are affected in their socializations, family relations and school performance (Zuckerbrot & Jensen, 2006). The effects of depression increase the risk for increased hospitalizations, recurrent depression, psychosocial impairment, alcohol abuse and antisocial behavior among adolescents (Zuckerbrot & Jensen, 2006). With suicide being among the leading causes of death among this age group, proactive assessment and treatment by the primary care provider is highlighted. Seventy-three percent of adolescents have at least one contract with a primary care provider every year, thus making the primary care setting a prime setting for identification and management of depressed adolescents (Asarnow et al., 2005). Identifying adolescent depression on a more regular basis may prompt the provider to initiate treatment and make appropriate referrals for mental health services. This will result in improvement in overall adolescent health and alleviate the burden of depression symptoms. A review of literature was conducted to determine what evidence and guidelines are available to guide the primary care provider in appropriately managing adolescent depression.
Review of the Literature A search of the literature was preformed regarding depression in the adolescent population in the following databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, PsychInfo, and The National Guidelines Clearing House. Additionally,

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Internet searches were performed for information related to the management of adolescent depression in the primary care setting. Keywords for the search included: adolescent depression, non-pharmacologic, treatment, management, complementary, alternative, and integrative. An additional search using specific therapy modalities including light therapy, art therapy, dance/movement therapy and music therapy was completed to attempt to increase the number of research studies with these identified treatment options.
Inclusion criteria were publication years from 2005-2015, written in the English language and based on participants between the ages of 13-18. Articles, such as studies of inpatient adolescents, postpartum depression of adolescent mothers, and depression in combination with other medical issues such as cancer, chronic pain and obesity were excluded. The National Guidelines Clearing House was searched for guidelines pertaining to adolescents and depression. The articles used for this review included meta-analyses, systematic reviews, randomized controlled trials, and clinically appraised primary research. A total of 29 articles and one guideline were reviewed. Results
Incidence. There are varying reports on the prevalence rates of adolescent depression. Costello, Erkanli and Angold (2006) found that 5.6% of adolescents in the community were depressed, with rates higher among girls than boys. There were similar findings among 18,000 respondents to a National Population Health Survey where 4.8% of boys and 8.7% of girls ages 12-19 years indicated at least one episode of major depression (Cairney, 1998). Taylor (2011) reported estimates of as many as 8% of the adolescent population in the US being diagnosed with a major depressive episode.

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Adolescence is a particularly vulnerable time for the development of depression due to development that occurs at this stage of life. Adolescence is a time for social, emotional and cognitive development. Depression can impede this development and lead to social isolation, limited coping abilities and academic failure. Other risks factors for the development of depression include prior depressive episodes, a first-degree relative with depression, school failure, interpersonal and familial stressors, negativistic coping skills, chronic illness and learning disabilities (Maslow, Dunlap, & Chung, 2015).
Impact. Depression has been associated with behavioral problems, poor school performance, early pregnancy, impaired social, work and family functioning and substance use (Cheung et al., 2013; Maslow, Dunlap, & Chung, 2015; Thombs, Roseman, & Kloda, 2012). Depression has also been shown to co-exist with other mental health issues such as anxiety, substance abuse and eating disorders as well as physical illnesses such as diabetes (Gray & Dihigo, 2015; Taylor, 2011). DiCola, Gaydos, Druss and Cummings (2013) identified one fifth of adolescents in the US with a major depressive episode also had a substance use disorder. Taylor (2011) found an association of depressive symptoms and drug use among a group of African American adolescents; symptoms included feeling sad, feeling like a failure, having experienced a loss of energy, feeling hopeless, having a loss of pleasurable activities and having family problems.
One of the most adverse outcomes of adolescent depression is suicide. Adolescents with depression show higher rates of suicidal ideation (Gray & Dihigo, 2015). Suicide is the third leading cause of death among US adolescents (Centers for Disease Control and Prevention, 2010).

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