Depression--When the Blues Get Darker

In this episode we discuss depression--when a child's sadness rises to the level of creating problems for them.

• WHAT IS DEPRESSION? 
  • sadness that rises to the level of depression as these thoughts, feelings and experiences become incapacitating or debilitating
• DOES DEPRESSION ALSO EXIST ON A SPECTRUM LIKE ANXIETY?

• DOES DEPRESSION LOOK DIFFERENT AT DIFFERENT TIMES OF LIFE?

• WHAT PROBLEMS CAN LOOK LIKE DEPRESSION?
   
• DO OTHER MENTAL HEALTH PROBLEMS HAPPEN ALONG WITH DEPRESSION?
   
• HOW MUCH IS NATURE VS NURTURE  WITH DEPRESSION?
   
• WHAT IS THE EVALUATION PROCESS FOR DIAGNOSING DEPRESSION?

• WHAT OUTSIDE HELP DO YOU BRING IN FOR DIAGNOSING DEPRESSION? 

• WHAT ABOUT SUICIDE THOUGHTS?  HOW DO WE MANAGE THOSE?
  
  
• WHAT IF THERE IS A CRISIS—A PARENT IS AFRAID FOR THEIR CHILD’S SAFETY RIGHT NOW?

• WHAT ARE THE NON-MEDICATION TREATMENT OPTIONS FOR DEPRESSION?
   
• SHOULD EVERYONE USE COUNSELING?

• HOW DOES A PARENT CHOOSE A GOOD COUNSELOR FOR THEIR CHILD?
  • 4 items to choose a counselor paragraph. Right insurance  right age right problem right fit 
  • I recommend counseling through therapist covered by your insurance.  Call or check on website to see: 1, who is covered; 2, the counselor who works primarily with patient's age group; 3, they help with the concern we have; and 4, they are a good fit for the patient--hobbies, interests, so they have something in common--best chance for a good therapeutic relationship
• ARE THERE COMPLIMENTARY THERAPY OPTIONS?

• WHAT ABOUT THE BASICS—SLEEP, EXERCISE?

• ANY BOOKS OR APPS THAT ARE AVAILABLE?
  • Stem 4 Apps
    • Move Mood—manage low mood and depression
    • Calm Harm—track and resist self harm
    • Worth Warrior—self-worth and eating issues
    • Calm Fear—help to manage anxiety
    • SafeUT--Safe Utah app super critical for being able to report concerns as well as get help
  • Books—books that utilize counseling therapy principles
    • Happiness Trap
    • Mind Over Mood
    •  Don’t Let Your Emotions Ruin Your Life
    •  Beyond the Blues
    • Think Good, Feel Good
• WHAT ABOUT NEW TECHNIQUES LIKE TMS (TRANSCRANIAL MAGNET STIMULATION) AND KETAMINE THERAPY

• WHO NEEDS MEDICATION?

• WHAT ARE THE MEDICATION OPTIONS FOR TREATING DEPRESSION?

• WHAT IF A PATIENT WON’T GO TO COUNSELING BUT WILL TAKE MEDICATION?  WILL YOU STILL PRESCRIBE FOR THEM?

• MANY PARENTS HAVE HEARD ABOUT GENETIC TESTING FOR PRESCRIBING—TELL US MORE ABOUT THAT.

• ARE THERE ANY SIDE EFFECTS OF TREATING WITH MEDICATION?

•   SHOULD PARENTS BE AFRAID OF SIDE EFFECTS WITH LONG-TERM USE?

• PARENTS MAY HAVE HEARD ABOUT A WARNING THAT ANTI-DEPRESSANTS INCREASE SUICIDE THOUGHTS.

• WHAT ARE THE CONSEQUENCES OF NOT TREATING?

• WHAT SHOULD PARENTS EXPECT FOR FOLLOW-UP  ONCE TREATMENT IS STARTED?

• ANY PARTING THOUGHTS ON TREATING DEPRESSION?

Transcript

IN THIS PODCAST WE CONTINUE OUR COVERAGE OF MENTAL HEALTH DIAGNOSES WITH A DISCUSSION OF DEPRESSION

• WHAT IS DEPRESSION? 
  • sadness that rises to the level of depression as these thoughts, feelings and experiences become incapacitating or debilitating
  • diagnosis has been constant over time—sad mood, lost of interest or motivation in doing things, feelings of guilt or worthlessness, problems making decisions
  • Changes in weight of >5% of body weight
  • suicidal thoughts
  • trouble falling asleep or staying asleep with subsequent fatigue
• DOES DEPRESSION ALSO EXIST ON A SPECTRUM LIKE ANXIETY?
   
  • Definitely—the more severe the symptoms—the sooner parents bring in their children.
•  
• DOES DEPRESSION LOOK DIFFERENT AT DIFFERENT TIMES OF LIFE?
   
  • irritability in younger children, less likely to be sad as younger kids—angry is common
•  
• WHAT PROBLEMS CAN LOOK LIKE DEPRESSION?
   
  • Any grief or bereavement from loss
•  
  • recent life stressors
•  
  • anemia
•  
  • thyroid issues
•  
  • vitamin D deficiency
•  
  • chronic illnesses
•  
• DO OTHER MENTAL HEALTH PROBLEMS HAPPEN ALONG WITH DEPRESSION?
   
  • Anxiety!
•  
  • ADHD—get down on themselves
•  
  • Contribute to one another
•  
• HOW MUCH IS NATURE VS NURTURE  WITH DEPRESSION?
   
  • Family history is the largest contributor to depression
•  
  • Environmental factors—early life trauma and experience with familial depression; poverty; loss and bereavement; kids without resilience and grit
•  
• WHAT IS THE EVALUATION PROCESS FOR DIAGNOSING DEPRESSION?
   
  • Screening every child from 11 years on
•  
  • Asking “how are you doing” opens the door to sharing concerns that may not be evident
•  
• WHAT OUTSIDE HELP DO YOU BRING IN FOR DIAGNOSING DEPRESSION? 
  • For the most comprehensive evaluation I recommend evaluation by a neuropsychologist to make sure we are working on the right diagnosis--most thorough and comprehensive evaluation of mental health and brain function
  • Psychiatrist for help with prescribing if more help is needed or if behavior is complicated—bipolar or other mood disorders
• WHAT ABOUT SUICIDE THOUGHTS?  HOW DO WE MANAGE THOSE?
   
  • Suicide—no one wants to die, they just want to stop hurting
•  
  • Hopelessness—feel there isn’t a way to get better and stop feeling this way
•  
  • These problems always do better in the sunshine.
•  
  • Talking about the suicide shines light on the problem to provide illumination ad a hope for help
•  
• WHAT IF THERE IS A CRISIS—A PARENT IS AFRAID FOR THEIR CHILD’S SAFETY RIGHT NOW?
   
  • No way a parent can monitor a child’s safety 24/7
•  
  • ER to meet with crisis counselor
•  
• WHAT ARE THE NON-MEDICATION TREATMENT OPTIONS FOR DEPRESSION?
   
  • Counseling is first on my list—Cognitive Behavioral Therapy (CBT) is the gold standard for treatment
•  
• SHOULD EVERYONE USE COUNSELING?
   
  • YES.  Everyone benefits from counseling.
•  
  • Provides tools to manage intrusive thoughts and experiences
•  
  • Safe.
•  
  • No medication
•  
• HOW DOES A PARENT CHOOSE A GOOD COUNSELOR FOR THEIR CHILD?
   
  • 4 items to choose a counselor paragraph. Right insurance  right age right problem right fit 
• 
  
  • I recommend counseling through Aspire or other covered therapist.  Call or check on website to see: 1, who is covered; 2, the counselor who works primarily with patient's age group; 3, they help with the concern we have; and 4, they are a good fit for the patient--hobbies, interests, so they have something in common--best chance for a good therapeutic relationship
•  
   
• ARE THERE COMPLIMENTARY THERAPY OPTIONS?
   
  • light box therapy—or go to Hawaii—always happy to prescribe that
•  
  • Vitamin D huge in Utah—almost everyone is low by the end of winter
•  
  • Happy to discuss any therapies parents are considering—I am not an expert in all that is out there and happy to discuss them and learn about them
•  
  • I know that many people use other resources and I am happy to discuss anything being used to help their child
•  
• WHAT ABOUT THE BASICS—SLEEP, EXERCISE?
   
  • Definitely
•  
  • Trying to evaluate cause and effects—is one contributing to the other
•  
  • sleep hygiene—probably the most important modifiable factor—all elements of brain function have a lower threshold for problems—from seizures, to migraines, to mental health—when someone gets inadequate sleep
•  
  • exercise
•  
  • hydration and good nutrition
•  
• ANY BOOKS OR APPS THAT ARE AVAILABLE?
   
  • Stem 4 Apps
     
    • Move Mood—manage low mood and depression
  •  
    • Calm Harm—track and resist self harm
  •  
    • Worth Warrior—self-worth and eating issues
  •  
    • Calm Fear—help to manage anxiety
  •  
    • SafeUT--Safe Utah app super critical for being able to report concerns as well as get help
  •  
• 
  
  • Books—books that utilize counseling therapy principles
     
    • Happiness Trap
  •  
    • Mind Over Mood
  •  
    •  Don’t Let Your Emotions Ruin Your Life
  •  
    •  Beyond the Blues
  •  
    • Think Good, Feel Good
  •  
• 
  
• WHAT ABOUT NEW TECHNIQUES LIKE TMS (TRANSCRANIAL MAGNET STIMULATION) AND KETAMINE THERAPY
   
  • Not approved for use in teens and children
  • TMS—magnetic field to align electrons in brain
  • Ketamine—dissociative
• 
  
• WHO NEEDS MEDICATION?
   
  • Those whose depression is in the moderate to severe range on screening and
•  
  • Those whose function is severely impacted by depression
•  
  • Reminder: Combo of medication and counseling is always better in combination than medication by itself
•  
• WHAT ARE THE MEDICATION OPTIONS FOR TREATING DEPRESSION?
   
  • SSRI—Zoloft, Prozac, Lexapro.  Most evidence for Prozac
•  
  • Start early or start later
•  
  • 6-12 months, trial off medication during a low stress time of the year
•  
  • We start with a low dose—“start low and go slow”—and then slowly work up to the expected effective dose.
•  
  • It takes about 4-6 weeks to reach reliable effectiveness, but there are benefits that begin right away
•  
  • Recommended to try two SSRIs before changing medications.
•  
  • Open to choosing a medication based on what is effective for other family members
•  
• WHAT IF A PATIENT WON’T GO TO COUNSELING BUT WILL TAKE MEDICATION?  WILL YOU STILL PRESCRIBE FOR THEM?
   
  • Yes.  So hard if a child doesn’t want to utilize counseling but sometimes the improvement from medication can open the door to accepting counseling and helps them do better in therapy
•  
• MANY PARENTS HAVE HEARD ABOUT GENETIC TESTING FOR PRESCRIBING—TELL US MORE ABOUT THAT.
   
  • Provides insight into understanding which medications are more likely to not work or more likely to cause side effects—helps us get to a successful medication twice as quickly
•  
• ARE THERE ANY SIDE EFFECTS OF TREATING WITH MEDICATION?
   
  • At the beginning some can have some stomach discomfort or nausea.
•  
  • Some have some dizziness.
•  
•   SHOULD PARENTS BE AFRAID OF SIDE EFFECTS WITH LONG-TERM USE?
   
  • No
•  
  • Good safety data
•  
  • No adverse effects of long-term use of medication
•  
  • No addiction or abuse potential
•  
• PARENTS MAY HAVE HEARD ABOUT A WARNING THAT ANTI-DEPRESSANTS INCREASE SUICIDE THOUGHTS.
   
  • 9 studies were reviewed.  4% of patients in medication group vs 2% not on medications had an increase in suicidal thoughts.
•  
  • Suicide ideation and attempts increased after this warning came out as less anti-depressants were prescribed
•  
  • Not treating depression increases our suicide rate
•  
• WHAT ARE THE CONSEQUENCES OF NOT TREATING?
   
  • Change their trajectory in life—not as good with leaving depression untreated
•  
  • Bad alternative to leaving untreated
•  
  • self-medicating with alcohol and THC
•  
• WHAT SHOULD PARENTS EXPECT FOR FOLLOW-UP  ONCE TREATMENT IS STARTED?
   
  • Trial of medication for the next month.  Follow-up in 1 month
•  
  • Repeat PHQ-9 (depression)  and GAD-7 (anxiety) testing
•  
  • Counseling with a therapist is a very important part of treatment to give tools to manage depression.
•  
  • Rx Match testing--pharmacogenetic testing to guide prescribing.  Genetic testing to know which medications will work best, which will cause side effects, and which medications will not be effective.
•  
  • If medication works well then will continue and possibly increase dose. 
• 
  
  • If medication does not work well or side effects are problematic then will change class of medication.
•  
  • Safety contract to talk with parent if patient has thoughts of self-harm, especially if patient has a plan for how to suicide.
•  
• ANY PARTING THOUGHTS ON TREATING DEPRESSION?
   
  • I am happy to help start the process of helping with mental health challenges with my patients and recommend resources for treatment, higher levels of evaluation and higher levels of prescribing:
•  
  • Empowerment
•  
  • WHY of taking medicine, no one is perfect, take to be your best self, Depression blue glasses metaphor, take for yourself and not for others 
• 
  
  • For those that don’t know what depression and anxiety feel like—it is very helpful to understand the many factors that contribute to these conditions—physical, physiologic, psychological, spiritual
•