Mood Disorders in Childhood and Adolescence

1. Dr. Oğuzhan Zahmacıoğlu Yeditepe Üniversitesi Hastanesi Çocuk ve Ergen Psikiyatrisi Mood DisordersinChildhood and Adolescence

2. Major Depressive Disorder: Diagnostic Criteria 5 of following symptoms, must include one of first two, occurred almost every day for two weeks • Depressed mood • Pleasure or interest/ Loss • Appetite • Sleep disturbance, too much or too little • Agitation or retardation • Fatigue • Feelings of worthlessness or guilt • Difficulty concentrating or deciding • Recurrent thoughts of death

3. Depressive Symptoms Mnemonic:“Space Drags S leep disturbance Pleasure/interest (lack of) Agitation Concentration Energy (lack of)/fatigue Depressed mood R etardation movement Appetite disturbance Guilt, worthless, useless

4. Common presentation of Depression in Children • Frequent vague, non-specific physical complaints such as headaches, muscle aches, stomachaches or tiredness • Frequent absences from school or poor performance in school • Talk of or efforts to run away from home • Outbursts of shouting, complaining, unexplained irritability, or crying • Being bored • Lack of interest in playing with friends • Alcohol or substance abuse

5. Common presentation of Depression in Children • Social isolation, poor communication • Fear of death • Extreme sensitivity to rejection or failure • Increased irritability, anger, or hostility • Reckless behavior • Difficulty with relationships

6. Assessment • Consider the following when assessing a child/young person • with depression and record in the notes: • potential co morbidities • social, educational and family context for the patient and family members • quality of patient’s relationships with family members, friends and peers.

7. Assessment • Assess the young person with their social network before treatment starts • identify factors that: – contributed to the development and maintenance of depression – impact in a positive or negative way on treatment efficacy. • Indicate ways to work in partnership with their social and • professional network

8. Assessment • Always ask the child/young person and their parents directly about the patient’s: – alcohol and drug use – experience of being bullied – experience of being abused – self-harm – ideas about suicide

9. Assessment • Give young people the opportunity to discuss these issues initially in private. • Pay special attention to: – confidentiality – young person’s consent (including competence) – parental consent – child protection

10. Assessment Consider parents’ mental health ● Consider the possibility of parental depression and substance misuse (or other mental health problems and associated problems of living). ● Obtain a family history to check for uni-polar or bipolar depression in parents and grandparents in all children/young people with suspected mood disorder.

11. General treatment considerations • Treat most children/young people on an outpatient or community basis

12. Mild depression • Antidepressant medication should not be used for the initial treatment of children and young people with mild depression

13. Moderate to severe depression first-line treatment: • specific psychological therapy • individual cognitive behavioral therapy [CBT], • interpersonal therapy or • shorter-term family therapy • it is suggested that this should be of at least 3 months’ duration. • Antidepressant medication should not be offered to a child or young person with moderate to severe depression except in combination with a concurrent psychological therapy

14. Fluoxetine should be prescribed as this is the only antidepressant for which trials show that benefits outweigh the risks. • The starting dose should be 10 mg daily, increased if necessary to 20 mg daily after 1 week. • Consider lower doses for children of lower body weight. • ●).

15. Consider the use of another antidepressant (sertraline or citalopram are the recommended second-line treatments • The starting dose should be half the daily starting dose for adults, • increased if necessary to the daily adult dose gradually over 2 to 4 weeks. Consider lower doses in children of lower body weight

16. Length of treatment • After remission (no symptoms and full functioning for at least 8 weeks) continue medication for atleast 6 months (after the 8-week period).

17. Childhood Bipolar Disorder • Forget a lot of what you know about adult bipolar disorder symptoms • symptoms of bipolar in children are quite different. Mood swings in children can be extremely fast, and various angry and irritable behaviors are very common.

18. Symptoms of mania • euphoria (elevated mood)—silliness or elation that is inappropriate and impairing • grandiosity • flight of ideas or racing thoughts • more talkative than usual or pressure to keep talking • irritability or hostility when demands are not met • excessive distractibility • decreased need for sleep without daytime fatigue • excessive involvement in pleasurable but risky activities (daredevil acts, hyper sexuality) • poor judgment • hallucinations and psychosis For an episode to qualify as mania, there must be elevated mood plus at least three other symptoms, or irritable mood plus at least four other symptoms.

19. Symptoms of depression • lack of joy and pleasure in life • withdrawal from activities formerly enjoyed  • agitation and irritability • pervasive sadness and/or crying spells • sleeping too much or inability to sleep • drop in grades or inability to concentrate • thoughts of death and suicide • fatigue or loss of energy • feelings of worthlessness • significant weight loss, weight gain or change in appetite

20. Challenges in Diagnosing Children's Bipolar Disorder • Distinguishing between normal behaviors and those that may indicate bipolar disorder in a kid is more challenging because: • There are a significant number of other conditions whose symptoms overlap with bipolar disorder, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), obsessive compulsive disorder (OCD), anxiety, depressive disorders and learning disabilities

21. Lines of treatment A good treatment plan includes • Medication, • Close monitoring of symptoms, • Education about the illness, • Counseling or psychotherapy for the individual and family, • Stress reduction, • Good nutrition, • Regular sleep and exercise, and • Participation in a network of support.

22. Psychotherapy can help patients and their families understand the illness, can teach the importance of early relapse detection, and ensure compliance with medication • It include: • Cognitive behavioral therapy • multi-family support groups

23. Medication • Atypical Antipsychotics Agents • Risperdal, Zyprexa, Seroquel, Aripiprazole– These newer agents are often used to treat bipolar disorders in adults, children and adolescents and appear to be effective mood stabilizers • Mood Stabilizers • Lithium • anticonvulsant • sodium valproic acid • Carbamazepine • Oxcarbazepine • Lamotrigine

24. Epidemiology • Depression in children and adolescents is associated with an increased risk of suicidal behaviors. • This risk may rise, particularly among adolescent boys, if the depression is accompanied by conduct disorder and alcohol or other substance abuse.

25. During the 1980s, mental health professionals began to recognize symptoms of mood disorders in children and adolescents, as well as adults. • However, children and adolescents do not necessarily experience or exhibit the same symptoms as adults.It is more difficult to diagnose mood disorders in children, especially because children are not always able to express how they feel.

26. “There are recent concerns that antidepressants may increase risk of suicidality in a few children and adolescents. These drugs are now labeled with warnings about suicidality. Paradoxically, several studies suggest that, overall, use of antidepressants significantly reduces risk of suicide. How to interpret these contradictory findings is unclear.”

27. Diagnosis & Prognosis • Those who have mild to moderate symptoms, who have a good response to treatment, and who remain adherent and cooperative with treatment have an excellent prognosis. • However, treatment response is often incomplete, and adolescents are notoriously nonadherent to drug regimens.For such adolescents, the long-term prognosis is not as good. • Little is known about the long-term prognosis of prepubertal children diagnosed with bipolar disorder based on highly unstable and intense moods.

28. Treatment • · Mood stabilizers, antipsychotics and antidepressants • · Psychotherapy • Drugs that are highly successful during initial stabilization may be unacceptable for maintenance because of adverse effects, most notably weight gain. • Antidepressants may trigger a switch from depression to mania; therefore, they are usually used with a mood stabilizer.

29. Suicidal Behavior in Children and Adolescents • Suicide is the 2nd or 3rd leading cause of death in 15- to 19-yr-olds and remains a considerable public health concern.

30. Predisposing factors include: • · Depression (implicated in > ½ of suicidal behaviors in adolescents) • · History of suicide in family members or close friends • · Recent death in the family • · Substance abuse • · Bipolar disorder • · Psychosis • · Conduct disorder, characterized by poor control of aggressive impulses against others, possibly redirected against self

31. Other contributing factors may include a lack of structure and boundaries, leading to an overwhelming feeling of lack of direction, and intense parental pressure to succeed accompanied by the feeling of falling short of expectations. • A frequent motive for a suicide attempt is an effort to manipulate or punish others with the fantasy “You will be sorry after I am dead.”

32. A rise in suicides is seen after a well-publicized suicide (eg, of a rock star) and among groups (eg, a high school, a college dormitory) in which a suicide occurred, indicating the power of suggestion. Early intervention to support youths in such circumstances may be helpful.

33. Lethality of suicidal intent can be assessed based on the following: • · Degree of forethought evidenced (eg, by writing a suicide note) • · Steps taken to prevent discovery • · Method used (eg, firearms are more lethal than pills) • · Degree of self-injury sustained • · Circumstances or immediate precipitating factors surrounding the attempt

34. Treatment • · Possibly hospitalization • · Possibly drugs to treat underlying disorders • · Psychiatric referral • Every suicide attempt is a serious matter that requires thoughtful and appropriate intervention. Once the immediate threat to life is removed, a decision regarding the need for hospitalization must be made. The decision involves balancing the degree of risk with the family's capacity to provide support.

35. Prevention • Suicidal incidents are often preceded by behavioral changes (eg, despondent mood, low self-esteem, sleep and appetite disturbances, inability to concentrate, truancy from school, somatic complaints, and suicidal preoccupation), which often bring the child or adolescent to the physician's office. Statements such as “I wish I had never been born” or “I would like to go to sleep and never wake up” should be taken seriously as possible indications of suicidal intent. A suicidal threat or attempt represents an important communication about the intensity of experienced despair.