Amid evidence that fewer than half of depressed adolescents get treatment for their emotional distress, a federal task force has recommended that physicians routinely screen children between 12 and 18 for depression and have systems in place either to diagnose, treat and monitor those who screen positive or to refer them to specialists who can.
The new recommendations, issued Monday by the U.S. Preventive Services Task Force, bring depression screening for adolescents into line with recently issued depression-screening recommendations that apply to adults.
Collectively, the new guidelines mean that virtually all Americans older than 12 will be checked periodically for persistent signs of sadness or irritability, changes in sleep, energy and appetite, or feelings of guilt or worthlessness. Where depression appears present in a patient, physicians who care for him or her should be ready to recommend treatment.
In the case of older children who screen positive for depression, treatment is a more complicated matter than for most adults. For patients younger than 18, the Food and Drug Administration has approved as safe and effective just two antidepressant medications in the selective serotonin reuptake inhibitor (SSRI) family: fluoxetine and escitalopram (marketed respectively as Prozac and Lexapro).
And the drug-safety agency has recommended especially close monitoring of patients under 24 taking an SSRI antidepressant because they are at increased risk of suicide and suicidal thoughts.
In teens and tweens, the panel found that both medication alone and psychotherapy alone were, at best, modestly effective in treating depression. When both modes of treatment were used together, however, depressed teens' mood and functioning were much more likely to improve.
Major depressive disorder is thought to affect about 8% of adolescents each year, and only between 36% and 44% report they have gotten treatment. Symptoms most typically appear around 14 to 15 years of age and are seen in girls nearly twice as commonly as in boys. Those who contend with early depressive episodes are more likely to suffer recurrences later in life.
And depression can be life-threatening. Between their 13th and 18th birthdays, just short of 20% of adolescents suffering from depression will attempt suicide. But depression is also a major contributor to poor school performance, deteriorating relationships and substance abuse in teens.
While depression is seen in children younger than 12, the federal panel said it had too little evidence to recommend depression screening for such children.
Columbia University psychiatrist Dr. Mark Olfson hailed the new recommendations, saying that well-care visits "provide an ideal opportunity to screen adolescents for depression." But he said that screening remains "infrequent" in primary care settings and is often overlooked even when physicians ask their young patients about depressive symptoms.
"The new recommendations have the potential to spur improved detection and appropriate triage of depressed adolescents," Olfson said.
The federal panel's new recommendation departs from its last look at the practice, drafted in 2009. The panel's earlier guidance proposed that physicians who were ready with treatment options, referrals and monitoring systems for depressed patients should go ahead and screen adolescents for depression.
Where that earlier recommendation essentially made such screening optional, the new recommendation asserts that physicians treating adolescents should already have such systems in place. It is widely seen as a reflection of depression care's move into the mainstream of modern medical practice -- a shift that should reduce stigma long attached to a common psychological affliction.
Rooting out depression in adolescents is not very different from doing so in adults: Several standard inventories exist that reliably detect depression symptoms, and physicians could administer them in person or on a questionnaire.
But the federal panel noted that in adolescents, irritability often replaces or coexists with sadness as a marker for depression. For adolescents in particular, several circumstances make depression more likely, including an individual's questioning his or her sexual or gender orientation, a recent breakup, family turmoil or violence, or poor academic performance.
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