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Depression/Anxiety

Objectives:

  1. Understand the screening and diagnosis of depression and anxiety
  2. Understand initial treatment of depression and anxiety
  3. Identify tools and resources for the primary care provider
  4. Identify resources for patients and families

Articles:

Additional Resources:

  • MCPAP for Providers - See separate sections for each diagnosis, with included guidelines/treatment suggestions, "clinical pearls" sheets, recorded lectures, parent handouts - pretty much everything! 
  • Check out the Hopkins Curriculum topic on Mental Health Issues in Primary Care to learn more and assess your knowledge.
  • Seattle Children’s Partnership Access Line has Care Guides, which include screening tools and treatment algorithms, and Resources for patients and families.

Self-Assessment:

1. A 13-year-old adolescent boy is brought to your office by his parents for behavioral concerns. His parents report that for the past month, their son has been withdrawn and uninterested in participating in any family activities. He quit the baseball team and his grades have dropped. He spends most of his time in his room. He is irritable when his parents talk to him and hard to wake in the morning for school. The boy has been healthy and is not taking any medications or supplements. When you interview him apart from his parents, his responses are brief and unrevealing. The review of systems is otherwise negative, and the boy’s physical examination findings are within normal limits. You recommend evaluation and treatment by a psychologist to address the adolescent’s symptoms. Of the following, the MOST evidence-based treatment for the adolescent’s condition is:

  1. cognitive behavioral therapy
  2. dialectical behavior therapy
  3. family therapy
  4. interpersonal therapy
  5. psychodynamic therapy

2. A 14-year-old girl comes to your office for a health supervision visit. During the interview, she discloses that on most days over the past month, she has been feeling irritable and sad. She has lost interest in going out with her friends and in playing basketball for her school’s team. It has been difficult for her to fall asleep. She feels tired and is finding it hard to pay attention at school. These symptoms have been worsening. The girl reports that she does not drink alcohol, smoke tobacco, or use drugs. She has been healthy and is not taking any medication or supplements. Although she reports no change in appetite, she has lost weight since her last visit. Her review of systems is otherwise negative, and her physical examination findings are within normal limits. You decide to prescribe a medication that has been approved by the US Food and Drug Administration for the treatment of this condition in adolescents, and for which additional medical tests are not indicated. Of the following, the medication that BEST fits this description is:

  1. citalopram
  2. escitalopram
  3. fluoxetine
  4. paroxetine
  5. sertraline

3. A 16-year-old adolescent girl is seen for a health supervision visit. She is healthy with no significant medical history. During a HEADSS (home and environment; education and eating; activities; drugs; sexuality; suicide, depression, and safety) assessment with her mother outside of the room, she reports that she identifies as being female but is attracted to both sexes. She has been dating a girl her age for the past 2 months and is feeling guilty because she does not believe her family will be accepting of this relationship. She becomes tearful and says that it has been difficult to lie to her parents about her feelings. She has never had sex of any type with a male or female partner. Of the following, the BEST next step in management is to:

  1. advise her to stop dating the female partner
  2. discuss birth control options and safe sex
  3. recommend therapy to explore her feelings
  4. start fluoxetine to address her depression

4. A 16-year-old adolescent girl with morbid obesity is seen for a health supervision visit. Her mother is concerned that she is failing 3 classes. During a HEADSS (home and environment; education, employment, and eating; activities; drugs; sexuality; suicide, depression, and safety) assessment, with her mother out of the room, the patient discloses that she is teased at school about her weight and that she feels alone because she does not have many friends. She reports that she has no suicidal thoughts. She has acanthosis nigricans on her neck and both axillae and several superficial well-healed scars on her left wrist. Of the following, the BEST next step in this patient’s evaluation and management would be to:

  1. order hemoglobin A1C and fasting plasma glucose tests
  2. provide information on adolescent weight loss programs
  3. refer her to a dietitian for nutrition counseling
  4. refer her to a psychologist for counseling

5. A 13-year-old boy comes to the office for follow-up of attention-deficit/hyperactivity disorder (ADHD). He was diagnosed with ADHD at 7 years of age and has done well with behavioral therapy, school supports, and stimulant medication. His mother reports that her son’s grades have been falling recently. He is no longer playing sports so that he can have more time to dedicate to his schoolwork. She is concerned about his motivation; she often finds him in his bedroom texting his friends or sleeping instead of doing his homework. When interviewed alone, the boy states that everything is “fine” and school is “boring.” His responses to the Patient Health Questionnaire 9 (PHQ-9) indicate a moderate level of depression. When discussing a management plan with his mother, warning signs for suicidal ideation and options for emergent evaluation are reviewed. Of the following, the behavior that would be of MOST concern is:

  1. conflict at school and home
  2. giving away belongings
  3. trouble falling asleep
  4. use of marijuana

6. An 8-year-old girl is brought to the office to discuss recent behavioral changes. Her mother reports that her daughter has been having frequent dreams about getting lost in a forest and wakes up crying. Every morning before school, she will persistently ask if she can go to work with her mother instead of going to school. During the day, the school nurse has called to report that the girl refuses to do her assigned work and instead will suddenly cry for no apparent reason. At home, she behaves well with no emotional outbursts, enjoys outings with her mother, and completes her homework without problems. Her mother reports that the behavioral problems started after her husband was deported. Of the following, the MOST likely diagnosis for this girl is:

  1. general anxiety disorder
  2. separation anxiety disorder
  3. social anxiety disorder
  4. specific phobia

7. A 14-year-old boy is brought to the office by his mother for behavioral concerns. He has refused to go to school for the past week. Before that, he was frequently tardy, telling his mother that he was not feeling well or that he did not have clean clothes to wear.  For a short time, she could get him to school without conflict if they arrived well in advance of the other students. The adolescent states that he feels like he is being “judged” by the other students when he arrives on campus. His mother states that he does not want to go on family outings and that he appears self-conscious and nervous when in public. The boy admits to feeling anxious and distressed in social situations and has been having a difficult time falling asleep due to excessive worries.  He recently asked his mother if he could be homeschooled.  Of the following, the MOST accurate statement regarding this boy’s behavior is that

  1. abnormal dopamine levels are correlated with the development of these symptoms
  2. behavioral inhibition is a risk factor for this condition
  3. children with these symptoms do not qualify for a Section 504 plan
  4. evaluation should include thyroid function studies

8. A 10-year-old boy is brought to the office by his mother for concerns about unusual behaviors.  She states that it is difficult to get him out of the house in the morning; he has been late to school on multiple occasions because he refuses to leave the house until he has everything he needs. Although she helps him gather and place his supplies and homework into his backpack the night before, in the morning, he will think of additional items that must be included.  On occasion, she has discovered him organizing and reorganizing his backpack in the middle of the night. It is difficult for her to convince him to discard scraps of paper or to remove old graded assignments from his binder, because he is concerned that he might need them in the future.  He had a meltdown when his mother cleaned out his backpack.  She wishes to learn what can be done to address these behaviors. Of the following, the BEST next step is to recommend

  1. a selective serotonin reuptake inhibitor
  2. cognitive behavioral therapy
  3. cognitive processing therapy
  4. organizational behavior management

Find the answers here.