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Mood Disorders Children and Adolescents

Mood Disorders Children and Adolescents. Waqar Waheed, MD FRCPC, DABPN Department of Psychiatry University of Calgary. Impact. Impaired relationships Poor school performance Substance use Legal problems Suicide. Mood Disorders: Depressive. Major Depressive Disorder Dysthymic Disorder

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Mood Disorders Children and Adolescents

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  1. Mood DisordersChildren and Adolescents Waqar Waheed, MD FRCPC, DABPN Department of Psychiatry University of Calgary

  2. Impact • Impaired relationships • Poor school performance • Substance use • Legal problems • Suicide

  3. Mood Disorders: Depressive • Major Depressive Disorder • Dysthymic Disorder • Depressive Disorder Not Otherwise Specified

  4. Statistics 1 in 250 pre-schoolers, 1 in 40 children, 1 in 12 adolescents suffers from depression (Birmaher et al 1996a)

  5. Etiology • The single most predictive factor associated with risk of developing MDD is…

  6. High family loading, heritability for MDD is 40 % • Craddock et al 2005

  7. Etiology • Biological Factors • Genetic Factors • Psychological Factors • Social Factors

  8. Biological Factors • Subnormal Growth Hormone Secretion (Ryan et al 1994) • Subnormal Thyroid Hormone Secretion (Dorn et al 1996) • Dysregulation of the Hypothalamic-Pituitary-Adrenal axis-Conflicting data (Birmaher et al 1996, Pfeiffer et al 1991)

  9. Neurotransmitters • Norepinephrine/Serotonin Dysregulation (Ryan et al 1990) • MRI Findings-Decreased frontal lobe volume and increased ventricular volume (Steingard et al 1996)

  10. Genetic Factors Concordance rates for depression are at least double in monozygotic twins(McGuffin and Katz 1989)than in dizygotic twins(Carlson and Abbott 1995)

  11. Lifetime risk for Major Depression in children of depressed patients ranges from 15%(Orvaschel et al 1988)to45%(Hammen et al 1990)

  12. Neuronal serotonin presynaptic reuptake site • People who have homozygosity or heterozygosity for the less functional allele for this site are most likely to develop MDD when exposed to recurrent negative life events • Caspi et al 2003, Kendler et al 2005

  13. Psychological Factors • Cognitive Behavioral Model • Research in children and adolescents supports the validity and clinical utility of this model (Brent et al 1997)

  14. Social Factors • Less Than 100% Twin Concordance • Positive correlation of life events with the onset of depression in children

  15. Major Depressive Disorder • Either 1. Depressed or Irritable Mood or 2. Anhedonia • Failure to make expected weight gains

  16. Dysthymic Disorder Depressed or Irritable Mood for at least one year

  17. “Double Depression” • Dysthymia has been theorized to be a “gateway” to recurrent mood disorders • Children usually have their first episode of Major Depressive Disorder 2-3 years after the onset of Dysthymia (Kovacs et al 1994)

  18. Clinical Presentation The expression of depressive symptoms varies according to age

  19. Pre-School Children • appear sad and slowed • limited verbal communication(Kashani and Carlson, 1987)

  20. mood congruent auditory hallucinationssomatic complaints(E.B. Weller et al 2004a)

  21. Adolescents • Delusions • Pervasive anhedonia

  22. Co-Morbidities • Up to 50% have two or more comorbidities • Anxiety Disorders • Disruptive Behavior Disorders • ADHD • Substance Use Disorders (Presenting symptom in 20% of depressed adolescents, Weller and Weller 2004)

  23. Mood Disorders: Bipolar • Bipolar I Disorder • Bipolar II Disorder • Cyclothymic Disorder • Bipolar Disorder Not Otherwise Specified

  24. Mood Disorders: Bipolar • Diagnostic (DSM-IV TR) Criteria are identical to those for adults • Less common than Depressive Disorders in this age group (Lifetime Prevalence 1%) (Levinsohn et al 1995) • 2 out of every 3 patients with Bipolar Disorder initially present with a Major Depressive Disorder

  25. Diagnostic Controversy • Use of the A/I phenotype • Wash U cardinal symptoms • Biederman group approach • CBCL phenotype

  26. A/I Phenotype • Also present in • ODD/CD • Autistic Disorder • ADHD • MDD

  27. Wash U Phenptype • Requires elation and/or grandiosity as cardinal symptoms

  28. Biederman group phenotype • Broad, there is no construct of cardinal symptom(s)

  29. CBCL Bipolar Phenotype • Includes hyperactivity and suicidal ideation/behaviors

  30. Proposed definitions of episodes and cycling phenomena

  31. Episode • Onset to offset of manic episode using DSM-IV TR criteria

  32. Ultra-rapid cycling • Mood “switches” every few days during an episode

  33. Ultradian Cycling • Mood “switches” multiple times daily during an episode • In 78-99% of children with Bipolar I (in 20 % of adult patient)

  34. Clinical Presentation The expression of manic symptoms varies in children according to their age

  35. Pre-School Children • Explosive/unmanageable temper tantrums • Sexualized behaviors • Nightmares with violent themes (Popper 1984)

  36. School Age Children • “Atypical" manic episodes among prepubertal children • Chronic, non-episodic, rapid cycling pattern (Geller and Luby 1997)

  37. Adolescents • Irritable/labile mood is MORE common than elevated/expansive mood • Psychotic features are MORE common than in adults (Ballenger et al 1992, McElroy et al 1997)

  38. Differential Diagnosis of Bipolar Disorder

  39. Differential Diagnosis of Bipolar Disorder • ADHD • Disruptive Behavior Disorders (ODD/CD)

  40. Suspect the presence of Bipolar Disorder in a child vs. ADHD if: • The ADHD symptoms appeared later in life (e.g., at age 10 years old or older) • The symptoms of ADHD appeared abruptly in an otherwise healthy child • The ADHD symptoms were responding to stimulants and now are not • The ADHD symptoms come and go and tend to occur with mood changes

  41. Bipolar Disorder vs. ADHD • A child with ADHD has recurrent severe mood swings, temper outbursts, or rages. • A child with ADHD has hallucinations and/or delusions. • A child with ADHD has a strong family history of bipolar disorder in his or her family,

  42. BIPOLAR DISORDER VS. DISRUPTIVE BEHAVIOR DISORDER • If a child has “off and on” oppositional or conduct symptoms or these symptoms only appear when the child has mood problems, • If a child has severe behavior problems that are not responding to treatment,

  43. BIPOLAR DISORDER VS. DISRUPTIVE BEHAVIOR DISORDER • If a child has behavior problems and a family history of BP disorder, • If a child has behavior problems and is having hallucinations and delusions.

  44. Cyclothymia In children and adolescents, the minimum duration of symptoms is 1 year

  45. Co-Morbidities • Occurrence of co-morbid disorders with bipolar disorders is close to 100% (Kessler et al 2001) • ADHD • Disruptive Behavior Disorders • Anxiety Disorders • Substance use Disorders

  46. Assessment • Clinical interviews of identified patient, family and school teacher

  47. Rating Scales • Children's Depression Inventory (CDI) • Children's Depression Rating Scale (CDRS)

  48. Hamilton Depression Rating Scale (HAM-D) • Young Mania Rating Scale-Parent Version (P-YMRS)

  49. Lab Tests • Thyroid Function Tests • Urine Drug Screen • Pregnancy Test

  50. Dexamethasone Suppression Test • Positive initial DST status in major depression does not add significantly to the likelihood of antidepressant response • Negative test (Cortisol suppressed in response to Dex) is not an indication for withholding antidepressant treatment • No relationship to suicidality

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