Doctors first line of defense in diagnosing depression in teens

Pediatricians may not have expected mental health to make up a significant part of their practice years ago. But today, it’s clear pediatricians are not only needed to care for adolescents’ physical health, but their mental health, too.

Nationwide, up to 20 percent of teens experience depression before age 20, according to the American Academy of Pediatrics. At Kaiser Permanente, 28 percent of adolescents coming through the primary care clinics have depression, anxiety or some other mental health issue, said Dr. Cynthia Seitz, pediatric physician in charge for Kaiser’s Southwest Washington region.

And pediatricians are the ones catching and diagnosing many of those kids, Seitz said.

“We’re on the front lines,” she said. “We’re identifying it first a lot of the time.”

With that in mind, the American Academy of Pediatrics last month published updated adolescent depression guidelines for primary care providers. The guidelines — the first update in a decade — target people 10 to 21 years old and call for universal adolescent depression screening every year for kids 12 and older.

The recommendations also urge primary care physicians to seek training in depression assessment, identification, diagnosis and treatment, and call on providers to collaborate with mental health resources in the community for consultations and family support. In addition, the guidelines offer recommendations for diagnosing and treating depression, urge providers to incorporate parents in the process, and give direction for creating safety plans.

“A lot of parents go to their pediatrician for the scraped knees and sore throats but don’t think of them when it comes to seeking help for emotional and behavioral issues,” said Dr. Rachel Zuckerbrot, a lead author of the guidelines, in a news release. “The American Academy of Pediatrics is supporting pediatricians, so that they are prepared to identify and treat these types of issues.”

At Kaiser, many of these processes are already in place, Seitz said.

At every wellness exam, pediatricians are screening kids for depression, anxiety and other mental health issues. As Seitz runs through questions about a patient’s overall health and wellness — asking about their diet, how much sleep they’re getting and whether they’re physically active — she slips in questions about their mood and whether they’re having fun with their friends.

“That helps normalize it as well,” Seitz said. “It’s just part of the regular checkup.”

Many adolescents have a trusted relationship with their pediatrician, making it more likely they’ll confide in their doctor about feelings they may not admit to an unknown medical provider or even a parent, she said.

But when pediatricians at Kaiser need backup, they need only to walk down the hall. In 2016, Kaiser hired 16 behavioral health consultants and embedded them in primary care clinics across the metro area. Seitz, who practices at the Orchard’s medical clinic, can bring a consultant in immediately to see a patient or make an appointment with the consultant for the patient before they leave the office.

The program has been so successful, Seitz said, Kaiser is considering adding more behavioral consultants to its primary care offices.

But Seitz wonders how feasible those processes are for smaller pediatric groups that don’t have behavioral health providers on staff.

“As I was reading these guidelines, I was thinking, ‘My word. How does a five-pediatrician private practice afford something like this?’ ” Seitz said.

The guidelines also pose challenges for larger multi-specialty clinics like Kaiser. The recommendations on follow-up care and monitoring, for example, would be tough to fulfill, Seitz said. In some cases, they call for weekly or monthly monitoring for a year, she said.

“There’s just not enough manpower,” Seitz said. “So the question is, ‘How do we do that work?’ ”

Added to the time demand, the recommendations on follow-up care aren’t backed up by research, Seitz said. Random, controlled studies on the effectiveness of monthly monitoring versus three-month follow-ups, for example, haven’t been done. Instead, the recommendations are based on expert consensus, Seitz said.

To keep up with monitoring now, Kaiser is utilizing technology. Pediatricians have two hours per week devoted to phone and video visits. Most are using that time to follow up with patients being treated for mental health issues. If a patient is diagnosed with depression, they’ll have a follow-up medication check. Then, Seitz said, the pediatrician will follow up again by phone a few weeks later. Seitz also emails her teenage patients, checking on their medications, side effects and mood.

“We can care for more patients that way, and we can have more immediate follow-up,” she said. “It makes it easier, but there’s still not enough manpower for the type of monitoring they’re recommending.”