“We’re trying to make other clinics aware that screening is feasible; it’s easy to do, even in a large volume clinic,” study investigator and pediatric psychologist Hillary Thomas, PhD, UT Southwestern Medical Center, Children’s Health System, Dallas, told Medscape Medical News.
Depression Highly Prevalent
“We know that many AEDs can have depression or mood effects as a side effect, and so we worry sometimes that our treatment could be causing or worsening depression,” study coauthor Susan T. Arnold, MD, professor, pediatrics, neurology and neurotherapeutics, and director of the Comprehensive Epilepsy Center at UT Southwestern, told Medscape Medical News.
There’s a “fair amount of evidence” that some factors that increase the risk for epilepsy also raise the risk for depression, said Arnold. Abnormalities in certain neurotransmitters or structural abnormalities in the brain can increase this risk.
Screening kids helps identify those who are vulnerable, “which is so easy for us to overlook otherwise,” said Arnold.
To screen for depression, the clinicians used the adolescent version of the 9-item Patient Health Questionnaire (PHQ-9). This assessment tool includes questions about impairment and about suicidal ideation.
The clinic has developed a protocol for responding to the varying levels of depressive symptoms.
“If they’re in that mild to minimal range of depressive symptoms, we don’t necessarily do anything specific in clinic, but we do educate regularly” and keep families up to date on monitoring, said Thomas.
For young patients in the moderate to severe range of depression, providers will speak to families and the clinic will connect them to behavioral health resources, she said.
A “gold standard” for treating depression is cognitive behavioral therapy, which helps patients identify negative thought patterns and change their behavior to improve mood. Some patients need a referral to a psychiatrist for medical management.
If a child indicates any suicidal ideation, regardless of the level of depressive symptoms, a pediatric psychologist or clinical social worker is paged.
“We then provide further risk assessment and create safety plans for families,” said Thomas.
For the study, researchers included 394 children aged 15 to 18 years who completed the PHQ-9 between June 2017 and May 2018.
The study found that 64% of subjects had minimal depressive symptoms, 20% had mild symptoms, and 9% had moderate or severe symptoms. About 7% had suicidal ideation and 16% required the behavioral health protocol.
Children should ideally be screened at every clinic visit, but at minimum once per year, said Arnold. Most kids come to the clinic every 6 months so it’s done at that time.
But staff were “positively surprised” at how smooth and nondisruptive the introduction was.
“Although we do sometimes need to call a social worker or psychologist down to clinic, it’s not that often; most of the time, children are not in a crisis situation. In retrospect, we wish we had started the screening sooner,” Arnold said.
“It didn’t complicate the clinic visit that much and we found ways of organizing our ability to refer to local mental health services when needed, and ways of building this information into our clinic workflow,” said Arnold.
The clinic has about 8000 visits a year from children with epilepsy.
“With such a large population, we feel that the information we’re collecting is something that is very valuable to share with other clinics,” said Arnold.
Clinic patients now fill out questionnaires using paper forms, but the aim is to introduce an online format that patients can complete on iPads when they come in.
Commenting on the findings for Medscape Medical News, Amy Brooks-Kayal, MD, codirector of the Translational Epilepsy Research Program, Ponzio Family Chair in Pediatric Neurology, and chief of pediatric neurology, Children’s Hospital Colorado in Aurora, said the study finding that 16% of the population needed some type of behavioral health intervention was informative.
“It highlights the importance of screening for emotional and behavioral comorbidities in adolescents with epilepsy. It also underlines the need for having a behavioral health protocol in place to manage the patients identified as needing intervention,” she said.
Arnold, Thomas, and Brooks-Kayal have disclosed no relevant financial relationships.