Recognizing-and-Managing-Depression-in-NAHIC:识别和管理在nahic抑郁课件.ppt
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- Recognizing and Managing Depression in NAHIC 识别 管理 抑郁 课件
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1、Recognizing and Managing Depression in Primary CareCharles E.Irwin,Jr.,MDDivision of Adolescent MedicineDepartment of PediatricsUniversity of California,San FranciscoFebruary 2014USPSTF Recommendation Screening of adolescents(12-18 yrs)for major depressive disorder(MDD)when systems are in place to e
2、nsure accurate diagnosis,psychotherapy(CBT or interpersonal)and follow up.March 2009 http:/www.ahrq.gov/clinic/uspstf09/depression/chdeprrs.htm Outline General Overview How to Make the Diagnosis Hx taking Physical exam Screening Instruments Epidemiology ManagementMajor Depressive Disorder Primary ca
3、re clinicians say of the teens they see:-9-21%have MDD Impact school performance Substance use/abuse Associated with increased risk of suicidal behaviorPossible Symptoms of MDD Appetite disturbance Sleep disturbance Fatigue or loss of energy Cardiopulmonary symptoms GI symptoms Neuromuscular symptom
4、s Gynecological symptoms Dermatological symptoms Behavioral symptomsHistory and Physical Exam Patient historyHEADSSS Family history(may need to ask parents separately)Complete physical exam BMI Neuro exam Consider labsHomeEducation/EmploymentEatingActivitiesDrugsSexSuicide/Safety StrengthsSIGECAPSlo
5、oks for criteria for Major Depressive DisorderS-Sleep disturbance:insomnia or hypersomniaI-Interest or pleasure:diminished in almost all activitiesG-Guilt:feelings of excessive worthlessness or guiltE-Energy:fatigue or energy loss nearly every dayC-Concentration:diminished.A-Appetite:weight loss or
6、decreased appetite P-Psychomotor agitation or retardationS-Suicide:recurrent thoughts of death or suicidal ideationScreening Instruments PHQ-A Patient Health Questionnaire for Adolescents BDI PC Beck Depression Inventory Primary CareSymptoms and Criteria for a Major Depressive EpisodeDepressed mood
7、or loss of interest or pleasure for a 2-week period(or irritability among children and adolescents),plus:Four or more of the following symptoms in the same 2-week period:Significant weight loss(when not dieting)or weight gain Insomnia or hypersomnia nearly every day Being restless or being slow(psyc
8、homotor agitation or retardation)Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt Inability to concentrate Recurrent thoughts of death or suicide ideations or plansDSM VSymptoms in Adolescents DSM-IV sx of MDDAs seen in teens Depressed mood mos
9、t of the dayIrritable or cranky moodLoss of interest in once favorite activitiesLoss of interest in sports,video games,activities with friendsWeight loss/gainSomatic complaints,failure to gain wtInsomnia/hypersomniaExcess late night TV,refusal to wake for schoolPsychomotor agitation/retardationTalk
10、of running away from homeFatigue,loss of energyPersistent boredomDecreased concentration,indecisivePoor school performance,frequent absencesLoss of self esteem,guiltOppositional/negative behaviorDepressive Symptoms in Teens More sleep and appetite disturbances,delusions,suicidal ideation and attempt
11、s,and impairment of functioning than younger children with MDD More behavioral problems and fewer neurovegetative symptoms than adults with MDD Differential Diagnosis of Depression Anemia Mononucleosis Hypothyroidism Hyperthyroidism Inflammatory bowel disease Collagen vascular diseaseMajor Depressio
12、n&Co-morbidity 76%with major depression also had other diagnoses,two thirds of which preceded the depression diagnosis.Previous diagnoses among the 76%include:Anxiety disorders(40%)Conduct disorders(25%)Addictive disorders(12%)Source:Kessler,1998Symptoms of Bipolar disorder in Adolescence:Markedly l
13、abile mood Agitated behavior Pressured speech Racing thoughts Sleep disturbances Reckless behaviors Illicit activities Spending sprees Psychotic symptoms such as hallucinations,delusions,irrational thoughtsRisk factors for Depression Genetics 20%have+family hx;female gender Biology puberty,premenstr
14、ual,postpartum Environment Family conflict,substance use at home Negative life events Divorce,loss of parent Individual factors Poor self esteem,poor school performance Co morbidities Mental health Chronic medical conditionsEpidemiology of Depression Prevalence of MDD in children(13 y.o.)is 2.8%,wit
15、h 1:1 ratio of girls to boys In adolescence(13-18 y.o.),prevalence is 5.6%,with a higher prevalence for girls than boys(5.9%vs.4.6%)Lifetime prevalence among adolescents is 20%.SOURCE?Depression:Broad MeasureSource:Grunbaum et al.,2008;YRBS;Self-reportSadness or Hopelessness which Prevented Usual Ac
16、tivities by Gender and Race/Ethnicity,High School Students,200734.6%17.8%34.5%24.0%42.3%30.4%35.8%21.2%Depression:Broad MeasureSource:Grunbaum et al.,2008;YRBS;Self-reportSadness or Hopelessness which Prevented Usual Activities by Gender and Race/Ethnicity,High School Students,2011Suicide:Seriously
17、ConsideredGender and Race/Ethnicity,High School Students,200817.8%10.2%18.0%8.5%21.1%10.7%18.7%10.3%Source:Grunbaum et al.,2008;YRBS;Self-reportEpidemiology of Depression At any given time,up to one in 13 adolescents have major depression making it more common than asthma Each successive generation
18、since 1940 is at greater risk of developing depression,and is identified at a younger agePrognosis 70%of youth with a major depressive episode will have another episode in next 5 years Youth with depression have a 4x increased risk of an adult depressive disorder 20-40%of children with major depress
19、ion will develop bipolar disorder eventually Can lead to impaired functioning in relationships,school etcPrinciples of Treatment Ensure safety Develop an alliance with the teen and parents Confidentiality?Psycho-education Addresses signs and symptoms of depression Stresses importance of psychotherap
20、y and psychiatric medications Addresses misconceptionsIndications for PCP Care vs.Specialist in Adolescents with DepressionIndications for PCP Initial episode of depression Absence of coexisting conditions Ability to make a no suicide contractIndications for Specialist Chronic,recurrent depression L
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