UPDATE: New Guidelines Published for Diagnosis and Treatment of Depression in Adolescents in Primary Care
March 7, 2018   

Depression in children and adolescence is an enormous issue, especially given the potential risk for suicide in this young patient population. Unfortunately, in the primary care setting (which is where many patients are initially or solely seen by clinicians) as many as 2/3 of pediatric patients with depressive symptoms are not diagnosed, and even when recognized, depression in children and adolescents is often suboptimal. For these reason, a group of experts from around the United States and Canada convened and published a set of consensus guidelines for the diagnosis and treatment of adolescent (age 10-21 years) major depressive disorder (MDD) in primary care, which have recently been updated.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC)
Primary care clinicians should seek training in depression assessment, identification, diagnosis, and treatment if they are not previously trained
Primary care clinicians should establish relevant referral and collaborations with mental health resources in the community
Adolescent patients ages 12 years and older should be screened annually for depression (MDD or depressive disorders) with a formal self-report screening tool
Patients with depression risk factors should be identified and systematically monitored over time for the development of a depressive disorder by using a formal depression instrument or tool
Primary care clinicians should evaluate for depression in those who screen positive on the formal screening tool, in those who present with any emotional problem as the chief complaint, and in those in whom depression is highly suspected despite a negative screen result. Clinicians should assess for depressive symptoms on the basis of established diagnostic criteria
Assessment for depression should include direct interviews with the patients and families and/or caregivers and should include the assessment of functional impairment in different domains and other existing psychiatric conditions. Clinicians should remember to interview an adolescent alone
Clinicians should educate and counsel families and patients about depression and options for the management of the disorder. Clinicians should also discuss the limits of confidentiality with the adolescent and family
After appropriate training, primary care clinicians should develop a treatment plan with patients and families and set specific treatment goals in key areas of functioning, including home, peer, and school settings
All management should include the establishment of a safety plan, which includes restricting lethal means, engaging a concerned third party, and developing an emergency communication mechanism should the patient deteriorate, become actively suicidal or dangerous to others, or experience an acute crisis associated with psychosocial stressors, especially during the period of initial treatment, when safety concerns are the highest
Primary care clinicians should work with administration to organize their clinical settings to reflect best practices in integrated and/or collaborative care models
After initial diagnosis, in cases of mild depression, clinicians should consider a period of active support and monitoring before starting evidence-based treatment
If a primary care clinician identifies an adolescent with moderate or severe depression or complicating factors and/or conditions such as coexisting substance abuse or psychosis, consultation with a mental health specialist should be considered. Appropriate roles and responsibilities for ongoing co-management by the primary care clinician and mental health clinician(s) should be communicated and agreed on. The patient and family should be active team members and approve the roles of the primary care and mental health clinicians
Primary care clinicians should recommend scientifically tested and proven treatments (ie, psychotherapies, such as CBT or IPT-A, and/or antidepressant treatment, such as SSRIs) whenever possible and appropriate to achieve the goals of the treatment plan
Primary care clinicians should monitor for the emergence of adverse events during antidepressant treatment (SSRIs)
Systematic and regular tracking of goals and outcomes from treatment should be performed, including assessment of depressive symptoms and functioning in several key domains (including home, school, and peer settings)
Diagnosis and initial treatment should be reassessed if no improvement is noted after 6 to 8 weeks of treatment. Mental health consultation should be considered
For patients achieving only partial improvement after primary care diagnostic and therapeutic approaches have been exhausted (including exploration of poor adherence, comorbid disorders, and ongoing conflicts or abuse), a mental health consultation should be considered
Primary care clinicians should actively support depressed adolescents referred to mental health services to ensure adequate management. Primary care clinicians may also consider sharing care with mental health agencies and/or professionals where possible. Appropriate roles and responsibilities regarding the provision and co-management of care should be communicated and agreed on by the primary care clinician and the mental health clinician(s)


Zuckerbrot RA et al. Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics 2018; Epub ahead of print.

Cheung AH et al. Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics 2-18; Epub ahead of print.

Accompanying Toolkit (free download).

     Additional information:

Implications of a Meta-Analysis of Antidepressants for Major Depressive Disorder in Children and Adolescents
SSRIs, SNRIs Show Small But Significant Benefit for Children and Adolescents With Common Mental Illnesses
Guidelines for the Recognition and Treatment of Depression with Mixed Features
Glad, Mad, or Sad: Diagnosing and Treating Pediatric Mood Disorders (Members only)