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Treatment of Mood Disorders in Children and Adolescents

Treatment of Mood Disorders in Children and Adolescents. Terrence Clark MD January 23, 2007. Treatment. GOOD TREATMENT BEGINS WITH GOOD ASSESSMENT. Objectives. Aware of the occurrence of mood disorders in children and adolescents

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Treatment of Mood Disorders in Children and Adolescents

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  1. Treatment of Mood Disorders in Children and Adolescents Terrence Clark MD January 23, 2007

  2. Treatment GOOD TREATMENT BEGINS WITH GOOD ASSESSMENT

  3. Objectives • Aware of the occurrence of mood disorders in children and adolescents • Share with you some of the literature that influences my treatment of mood disorders in children and adolescents • Aware of the phenotypes of Bipolar Disorder in children and adol

  4. Objectives • Treatment most often is multimodal • Pre-pubertal Bipolar Disorder may or may manifest as BP in adults • Adolescent BP phenotype is more similar to adult presentation • Aware of treatment guidelines

  5. Four Cases#1 • 20 year old man with depression • Hospitalized twice at ages 15 and 16 • Some marijuana and alcohol use • Age 18 relapses and takes 6 months to gain full remission • Paroxetine and mirtazepine and low dose clonazepam

  6. Case #2 • !6 year old girl with depression • “excellent” response to an SSRI • Clinician feels good about the excellent treatment outcome • Truth

  7. Case # 3 • 16 year old boy Bipolar Disorder • Hospitalized 4 times at ages 9, 10 (2), and 16 • Mood stabilized plus an atypical • Expelled from school at age 16- fighting

  8. Case # 4 • 10 year old boy • Anger, rage, aggression • Chronically impaired for 3 years • Family history of Bipolar • Responds well to a mood stabilizer plus an atypical antipsychotic

  9. Identification of Mood Disorders in kids is based upon Adult based DSM-IV Criteria with some modifications

  10. DSM • DSM III and DSM IV created as a guide to improve reliability of DX • Yet, once created, the diagnostic criteria become the disorder rather than a guide and the illness by definition equals a specified # of criteria • McClellan, J. JPL AACAP, 44:3, March 2005Commmentary on Treatment Guidelines

  11. Normal Children • Active • Imaginative • Boastful • Sensitive to the environment • “Act out” periodically

  12. Assessment • Interview of parents • Interview of child • Review of prior mental health records • Review of medical/PCP records • Psychological Inventories

  13. Interview of Parents • Birth and developmental history • Family history • Social • School • Medical • Marital

  14. Interview of Child • Kids will tell you what is going on if you follow their leads in the interview • Rapport • Let them know why you are interviewing them “doctor that helps kids with….” • Social distance

  15. Interview with kids • Listen to the patients story, following leads with open ended questions • Don’t squeeze the patient into a medical model shoe • Save medical model, closed-ended questions to the later part of the interview

  16. Major Depression • Epidemiology • Prevalence increases as age increases • less than 0.3-0.5% of preschoolers • 1-2% of prepubertal children • 5% of adolescents • 10-25% of women • 5-12% of men • Sex ratio • Prepubertal onset: male approximately equal female • Adolescence same as adult sex ratios (female > male: ~2:1) until 50 Years old

  17. Depressive Disorders in Children (cont) • Greater genetic loading then adult depression • High co-morbidity with other psychiatric disorders • Co-morbidity is the rule rather than the exception with childhood disorders

  18. Depressive Disorders in Children (cont) • Mortality – Risk of suicide - Estimated 8-10% of adolescents attempt suicide - Approximately 1% of preadolescents attempt suicide - Firearms account for a large percent of suicides in youth

  19. Major Depression • Criteria for Major Depressive Episode • 1. Depressed mood most of the day, • IN children and adolescent can be irritable mood.

  20. Adolescent Depression • Increased moodiness, irritability, argumentativeness • Poor concentration • Sleep and appetite changes • Increased self-criticism • Despair, sadness, emptiness • Loss of energy • Lack of interest in usual activities and friends • Increased talk of death and dying • Threats of suicide

  21. Course of Major Depression in Children and Adolescents • 7- 9 months average duration of episode • 90% recovered in 18 mos • 50% relapse • 40% another episode within 2 years • 70% another episode within 5 years • 6-10% have a chronic course

  22. Depression • Psychotherapy first • CBT • Interpersonal • Family • Psycho education

  23. Treatment for Youth with Major Depression • Psychoeducation of pt and family • Multimodal treatment • Medication rarely is the sole treatment • Psychosocial interventions 1st in preschool • Address safety • Treat co-morbid conditions • FDA warnings – share with pt and family

  24. CBT • Manualized therapy • Children’s group CBT • Multi-parent group CBT

  25. CBT Research • Comparison across studies is difficult due to variability in outcome assessment methodology • CBT studies rarely report on remission rates • Remission and Residual Symptoms after Short-term treatment of adolescents with Depression study (TADS) Jl. AACAP, 45:12, Dec. 2006

  26. Pharmacotherapy of Major Depression in Children and Adol • Fluoxetine- only FDA approved treatment • 2003- approved for treatment of Major Depression and OCD in children ages 7 thru 17

  27. Selecting an Antidepressant for Pediatric Depression • Fluoxetine efficacy supported by 3 independent multisite clinical trials (Emslie, TADS) • Fluoxetine is the only antidepressant whose efficacy has been compared with CBT, alone and in combination with fluoxetine • Emslie et al., 1997; 2002; TADS Team, 2004)

  28. Selecting Antidepressant • Fluoxetine – consider first, not necessarily prescribe first • Family response history toantidepressants • Indiv patient context, expectations and preferences • 20-40% of depressed youth do not adequately respond to fluoxetine

  29. Selecting antidepressant • Sertraline and citalopram- there is some literature supporting clinical efficacy • Citalopram, escitalopram – much lower potential for drug interactions • At least 8 adult studies, a person may respond poorly to one SSRI, then well to another • Sertraline – FDA approved for treatment of OCD, ages 6 • Selecting an antidepressant for the Treatment of Ped Depression Jl AACAP; 45:3; March 2006

  30. Pharmacotherapy of Maj Dep in Children and Adolescents • Emslie et al. 96 children, ages 7-17, mean age 12.35, dbl bl, placebo controlled 8 weeks • Fluoxetine significantly better than placebo

  31. Treatment of Depression in Children - Pharmacotherapy • SSRI’S – all SSRI’s effective • Recent concern regarding risk of increased suicidal thinking in children taking antidepressants • Tricyclic antidepressants – no proven efficacy, more side effects, fatal in overdose

  32. BIPOLAR DISORDER

  33. Bipolar Disorder • Epidemiology: • Occurs in 1% of adults • About 20% bipolar patients have first episode in adolescence • Clear mania in children as young as 6 years old • Gender ratio males = females • 10-15% of adolescents with recurrent major depression develop bipolar disorder

  34. Bipolar Disorder • Clinical Description • First symptoms usually depressive • Psychotic symptoms commons • therefore misdiagnosed as schizophrenia • Hyperactivity, pressured speech, distractibility

  35. NIMH Research Roundtable on Pre-Pubertal Bipolar Disorder • Significant number of children do not meet full diagnostic criteria for bipolar disorder • Recommended use of “Bipolar disorder not otherwise specified”, BP-NOS • For children with manic symptoms, i.e. irritability and aggression • Journal of ACAP, 40:8 August, 2001

  36. Comorbidity in Adolescent Inpatients with Bipolar Disorder (N=34) West et al, Biol Psych 1996;39:458-460

  37. Pediatric Bipolar DisorderTwo Phenotypes • Pre-pubertal and early adolescent onset bipolar disorder (PEA-BD) – a broad phenotype • Adolescent onset bipolar disorder (AO-BD) a Narrow phenotype: classical mood cycling, adolescent onset

  38. Prepubertal and early adolescent Bipolar Disorder (PEA-BD) • Irritability, rapid cycling, little inter-episode recovery • Emotional dysregulation, rage , meltdowns • Early sudden onset of depression and psychomotor retardation • Pharmacologically induced mania • Family history of Bipolar Disorder • Strober M, Carlson GA.Arch Gen Psy. 1982;39:549-555

  39. Adolescent onset Bipolar Disorder (AO-BD) • Episodic course in at least 25% of patients • High rates of substance abuse • High rates of anxiety symptoms • Often presents with classic symptoms of adult mania including psychosis • May be confused with schizophrenia

  40. Differential PEA-BD vs. ADHD • Five DSM-IV criteria do not overlap: • Elation • Grandiosity • Racing thoughts/flight of ideas • Decreased need for sleep • Hypersexuality

  41. Similarities: PEA-BD and AO-BD • Elated mood • Mixed episodes, long duration episodes • low inter-episode recovery

  42. Is Bipolar Disorder common in Children? (pro/con) • Pro: • Unstable, labile mood • Hyperactivity, Sleep dis., racing thoughts aggression • Mixed presentation • Chronic, leading to severe disability • Bipolar Disorder is Common in Children (Pro/Con), Gianni Faedda vs Gabrielle Carlson, The JL of BP Disorders, Vol 3

  43. Con (Carlson) • Prepubertal Bipolar kids rarely become classic BP adults • This is a new concept to define the prepubescent presentation as BP • Yet, 64% of BP adults in Suffolk Co study had childhood psych problems • DSM IV gentrified ADHD removing mood symptoms…. Thus new home “BPD NOS”

  44. DSM and the Increased Diagnosis of Childhood Bipolar Disorder • ADHD prior to DSM III, 1981, called “Minimal Brain Damage” (MBD”) • Affective symptoms: depression, mania, anger, tantrums and rage • MBD included affective symptoms and mood liability • DSM III eliminated affective symptoms from ADHD

  45. Is this the same disorder as in adults? • Limited data • Do not suggest that pre-pubertal bipolar disorder evolves into the classic adult illness (McClellan, 2005) • Adolescent bipolar disorder predicts an increase in psychopathology and adverse outcomes, antisocial and borderline personality symptoms (Lewinsohn, et al.,2000) • Classical BPD, adol, likely leads to adult BPD

  46. Two Year Outcome of Bipolar Children (Geller) • 89 outpt subjects with presence of mania • Mean age 10.9 years • Eval at 6,12,18, and 24 months • Naturalistic study, outpt sites • Required elation or grandiosity • Mean age of onset 7.3 years (SD =3.5) • Mean duration baseline episode 3.6 years Geller et al, AmJ Psychiatry, 159:927-933

  47. Two Year Study (continued) • Poor outcome: • 65% recovered from mania • Yet 55% relapsed • 36 weeks mean time to recovery • Relapse after a mean of 28 weeks Geller et al

  48. Bipolar Disorder in Adolescence • Rapid cycling in 80% • Mixed mania in 58% • Frequent psychotic mania • Co-morbid ADHD and conduct disorders • Suicidality in 46% • Marked impairment • Prepubertal depression Geller, et al. Am J Psychiatry. 2001;158:125-127.

  49. Differentiating Bipolar from other Disorders • Requires detailed history from multiple sources (“100% different story”) • Qualitative changes from baseline • Persistence, severity-in multiple contexts • Typical clustering of symptoms

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