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Antidepressants and Mood Disorders Youth to Maturity

Antidepressants and Mood Disorders Youth to Maturity. Kansas Osteopathic Conference April 2008 CindyRuttan DO. If depression is creeping up and must be faced, learn something about the nature of the beast: You may escape without a mauling. Dr. R. W. Shepherd. Objectives. Definitions

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Antidepressants and Mood Disorders Youth to Maturity

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  1. Antidepressants and Mood DisordersYouth to Maturity Kansas Osteopathic Conference April 2008 CindyRuttan DO

  2. If depression is creeping up and must be faced, learn something about the nature of the beast: You may escape without a mauling.Dr. R. W. Shepherd

  3. Objectives • Definitions • Characteristics/Symptoms • Epidemiology • Comorbidity/Clinical course • Assessment/Evaluation • Treatment Options • SUICIDE UPDATE

  4. Definitions • Characteristics/Symptoms • Epidemiology • Comorbidity/Clinical course • Assessment/Evaluation • Treatment Options • SUICIDE UPDATE

  5. Major Depressive Disorder (MDD)is Classified as a Mood Disorder • Mood disorders are: • Disorders that have a disturbance in mood as the predominant feature • Mood disorders include: • Depressive disorders • Bipolar disorders American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:345-428.

  6. Major Depressive Disorder Single / Chronic / Recurrent Atypical Melancholic Catatonic Psychotic Postpartum onset Seasonal Dysthymic Disorder Depressive Disorder NOS Bipolar I Disorder Manic / Mixed episodes Bipolar II Disorder Hypomanic + Major Depression Cyclothymic Disorder Hypomanic + Depressive Bipolar Disorder NOS Mood Disorders Can be Depressive or Bipolar Depressive Disorders Bipolar Disorders Adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:345-428.

  7. Definitions • Characteristics/Symptoms • Epidemiology • Comorbidity/Clinical course • Assessment/Evaluation • Treatment Options • SUICIDE UPDATE

  8. Major Depressive Disorder Single / Chronic / Recurrent Atypical Melancholic Catatonic Psychotic Postpartum onset Seasonal Dysthymic Disorder Depressive Disorder NOS Bipolar I Disorder Manic / Mixed episodes Bipolar II Disorder Hypomanic + Major Depression Cyclothymic Disorder Hypomanic + Depressive Bipolar Disorder NOS Mood Disorders Can be Depressive or Bipolar Depressive Disorders Bipolar Disorders Adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:345-428.

  9. It's a recession when your neighbor loses his job; it's a depression when you lose yours.Harry S Truman33rd president of the United States, 1884-1972

  10. Summary:Major Depressive Disorder (MDD) • MDD is a mood disorder • Diagnostic criteria include both emotional and physical symptoms • MDD is often not detected and often under-treated • MDD is prevalent in the United States • MDD is costly to employers and children, and increases healthcare costs in the elderly • Remission is the goal of treatment • Treating all symptoms (emotional and physical) is associated with better long-term outcomes • Residual symptoms are often physical • Untreated MDD is associated with increased morbidity and mortality

  11. CConcentration A Appetite P Psychomotor S Suicide MDD: SIGECAPS • S Sleep D/O • IInterests • G Guilt • E Energy

  12. Thalamus Corpus Callosum Hypothalamus Cingulate Gyrus Hippocampus Ascending tracts for 5HT and NE Prefrontal Cortex(Orbitofrontal Cortex) Locus Coeruleus Amygdala Descending tracts for 5HT and NE Raphe Nuclei Serotonin (5HT) and Norepinephrine (NE) Pathways in the Human Brain • Most serotonin tracts originate in the raphe nuclei located in the midbrain. • Most norepinephrine tracts originate in the nuclei of the locus coeruleus located in the midbrain.

  13. MDD (continued) • Must have Depressed Mood and/or Anhedonia, or may just be Irritability in Children for a minimum of 2 weeks with additional 4 of the 8 symptoms • Recurrent means 2 months symptom-free between episodes.

  14. Major Depressive Disorder Single / Chronic / Recurrent Atypical Melancholic Catatonic Psychotic Postpartum onset Seasonal Dysthymic Disorder Depressive DisorderNOS Bipolar I Disorder Manic / Mixed episodes Bipolar II Disorder Hypomanic + Major Depression Cyclothymic Disorder Hypomanic + Depressive Bipolar Disorder NOS Mood Disorders Can be Depressive or Bipolar Depressive Disorders Bipolar Disorders Adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:345-428.

  15. DSM-IV-TR Associated Symptoms of A Major Depressive Episode (MDE) • Tearfulness • Irritability • Brooding or obsessive rumination • Anxiety or phobias • Excessive worry over physical health • Complaints of Pain • Headaches • Joint pain • Abdominal pain • Other pains American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:352.

  16. MDDCharacteristics • Developmental differences: endogenicity, melancholia, psychosis,suicide attempts, lethality of suicide attempts, and functional impairment increase with age. • Separation anxiety, phobias, somatic complaints, and behavioral problems increase with children.

  17. MDDCharacteristics (continued) • Psychosis • Children have more Auditory Hallucinations* • Adolescents and Adults exhibit more Delusions**

  18. Major Depressive Disorder Single / Chronic / Recurrent Atypical Melancholic Catatonic Psychotic Postpartum onset Seasonal Dysthymic Disorder Depressive Disorder NOS Bipolar I Disorder Manic / Mixed episodes Bipolar II Disorder Hypomanic + Major Depression Cyclothymic Disorder Hypomanic + Depressive Bipolar Disorder NOS Mood Disorders Can be Depressive or Bipolar Depressive Disorders Bipolar Disorders Adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:345-428.

  19. A Appetite C Concentration H Hopeless E Energy W Worthless S Sleep D/O Dysthymia

  20. Dysthymia(continued) • Two of the six criteria and a Depressed mood for two years with no more than one month of feeling normal. Children require only one year and may just have irritable mood.

  21. Dysthymic DisorderCharacteristics • Feelings of unresolved love, anger, somatic, self deprecation, anxiety and disobedience. • Fewer Melancholic features compared to MDD • About 70% estimate will go on to have MDD. Both MDD / DD diagnosis is called DOUBLE DEPRESSION.

  22. Major Depressive Disorder Single / Chronic / Recurrent Atypical Melancholic Catatonic Psychotic Postpartum onset Seasonal Dysthymic Disorder Depressive Disorder NOS Bipolar I Disorder Manic / Mixed episodes Bipolar II Disorder Hypomanic + Major Depression Cyclothymic Disorder Hypomanic + Depressive Bipolar Disorder NOS Mood Disorders Can be Depressive or Bipolar Depressive Disorders Bipolar Disorders Adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:345-428.

  23. Major Depressive Disorder Single / Chronic / Recurrent Atypical Melancholic Catatonic Psychotic Postpartum onset Seasonal Dysthymic Disorder Depressive Disorder NOS Bipolar I Disorder Manic / Mixed episodes Bipolar II Disorder Hypomanic + Major Depression Cyclothymic Disorder Hypomanic + Depressive Bipolar Disorder NOS Mood Disorders Can be Depressive or Bipolar Bipolar Disorders Depressive Disorders Adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:345-428.

  24. A Activity S Sleep T Talkative Manic Episode/ Hypomania • D Distraction • I Indiscretions • G Grandiose • F Flight of ideas

  25. Mania/Hypomania(continued) • 3 of the 7 criteria with an elevated mood for one week. • 4 of the 7 criteria with irritability for one week. • Hypomania: symptoms last at least four days

  26. Major Depressive Disorder Single / Chronic / Recurrent Atypical Melancholic Catatonic Psychotic Postpartum onset Seasonal Dysthymic Disorder Depressive Disorder NOS Bipolar I Disorder Manic / Mixed episodes Bipolar II Disorder Hypomanic + Major Depression Cyclothymic Disorder Hypomanic + Depressive Bipolar Disorder NOS Mood Disorders Can be Depressive or Bipolar Depressive Disorders Bipolar Disorders Adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:345-428.

  27. Cyclothymia • Depressive symptoms, yet does not meet criteria for MDD and Hypomanic type symptoms for two years. Children: one year. • During the duration, one can not be without the symptoms for more than two months at a time.

  28. Major Depressive Disorder Single / Chronic / Recurrent Atypical Melancholic Catatonic Psychotic Postpartum onset Seasonal Dysthymic Disorder Depressive Disorder NOS Bipolar I Disorder Manic / Mixed episodes Bipolar II Disorder Hypomanic + Major Depression Cyclothymic Disorder Hypomanic + Depressive Bipolar Disorder NOS Mood Disorders Can be Depressive or Bipolar Depressive Disorders Bipolar Disorders Adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:345-428.

  29. All diagnoses must include: • Can not be accounted for by other Mental Health disorders • Not caused by a substance or GMC • Must clinically cause significant distress or impairment in social, occupational, or other important areas of function

  30. Definitions • Characteristics/Symptoms • Epidemiology • Comorbidity/Clinical course • Assessment/Evaluation • Treatment Options • SUICIDE UPDATE

  31. Epidemiology Depression in youth • Estimated between .4 and 2.5% Prepubertal .4-8.3 % Adolescent(1:1/2:1 F/M) • Lifetime prevalence rate of MDD for adolescents is 15-20%(comparable to adults) • DD prevalence rate is .6-1.7% for children,1.6%-8.0% for adolescents

  32. Course of Disorderin Youth • Mean MDD length 7-9 months • 90% of MDD remit in 1.5-2 years; 6-10% protracted • MDD is recurrent: possibility of returning is 40% within 2 years and 70% by 5 years. • BADI / II: 20-40% of adolescents with MDD develop BADI within 5 years after the onset of Depression

  33. Course of Disorder(continued - from youth on) • DD protracted course with mean length 4 years. Associated with inc. MDD 70%, Bipolar 13%, and Substance Abuse 15% • First episode of MDD is usually about 2-3 years after DD.

  34. Factors associated with Onset of MDD • 50% transmission in adult twin studies suggest genetic connection. Subsequently, genetic studies point to environmental issues.

  35. Family Aggregation studies MDD DD Family/Environmental Stressful events Neg. Cognitive style Biologic markers GH Serotonin Hypothalamic/Pit. Dexamethasone suppression ACTH Sleep

  36. Sequelae in youth • Affects daily living • MDD occurs 4-5 years prior to the onset of substance abuse. Early identification of MDD can help prevent future substance abuse. • After recovery children and adolescents still show subclinical symptoms. • Adolescents with 2+ episodes have worse outcome.

  37. Who Gets Major Depressive Disorder (MDD)? • Nearly twice as prevalent in females 1 • Risk factors for MDD include:2 • family history of MDD • post partum period • medical comorbidity • stressful life events • current substance abuse 1. Kessler RC, et al. J Affect Disord 1993;29:85-96. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:345-428.

  38. Major Depressive Disorder (MDD) is a Common Disorder in the United States • 14.9% lifetime prevalence of MDD in the U.S. • 18.6% lifetime prevalence of MDD in women • 11.0% lifetime prevalence of MDD in men • 8.6% 12-month prevalence of MDD in the U.S. • 11.0% 12-month prevalence of MDD in women • 6.1% 12-month prevalence of MDD in men • The prevalence of 12-month and lifetime MDD is significantly more for women vs. men (p < .05) Kessler RC, et al. Br J Psychiatry Suppl 1996:17-30. Kessler RC, et al. Arch Gen Psychiatry 1994;51:8-19.

  39. Major Depression is a Major Cause of Disability World-Wide Adapted from: Murray CJ, Lopez AD. Science 1996;274:740-743.

  40. Cultural Variations in the Clinical Presentation of Patients with Major Depressive Disorder (MDD) May Obscurethe Diagnosis of MDD • Psychological distress may be expressed through somatic symptoms in many cultural groups including Latinos1, African Americans2, and Asian-Americans3 • These groups may be more likely to report: • Poor general health • Impairment in physical functioning • Multiple physical symptoms or bodily complaints 1. Escobar JI, et al. Arch Gen Psychiatry 1987;44:713-718. 2. Brown C, et al. J Affect Disord 1996;41:181-191. 3. Yeung A, et al. Acta Psychiatr Scand 2002;105:252-257.

  41. Definitions • Characteristics/Symptoms • Epidemiology • Comorbidity/Clinical course • Assessment/Evaluation • Treatment Options • SUICIDE UPDATE

  42. Comorbidity MDD • 40-70% of depressed children & adolescents have comorbid psychiatric disorders. • 20-50% have 2 or more comorbid diagnoses. • DD and Anxiety D/O (both 30-80%) • Disruptive D/O (10-80%) • Substance abuse (20-30%)* • Personality D/O (Borderline 30%)**

  43. Depressed Mood May Be Secondary to Another Condition • Specified general medical conditions • Prominent, persistent disturbance in mood • Direct physiological consequence of the medical condition • Degenerative neurological conditions • Cerebrovascular disease • Metabolic conditions • Endocrine conditions • Autoimmune conditions • Viral or other infections • Cancer • Medication or other substance use • Prominent, persistent disturbance in mood • Direct physiological consequence of: • Medication • Drug Abuse • Toxin Exposure American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:352.

  44. Comorbidity DD • 70% have MDD • 50% have pre-existing psych. history. • 40% anxiety • 30% conduct • 24% ADHD • 15% enuresis and encopresis • 15% have 2 or more comorbid etio.

  45. Major Depressive DisorderMay Be Associated with Neuroanatomic Changes • Depressed vs. Non-depressed Elderly Patients1 • Smaller hippocampal volume in depressed • Smaller prefrontal cortex volume in depressed • Severely Depressed Patients vs. Normal Controls • Reduced hippocampal volume in depressed2 • Reduced hippocampal volume in depressed patients in remission for 4-7 months2 • Longer time that depression was untreated was significantly related to reduced total hippocampal gray matter volume3 • Postmortem Studies From Depressed Patients2 • Loss and shrinkage of neurons in the prefrontal cortex 1. Bell-McGinty S, et al. Am J Psychiatry 2002;159:1424-1427. 2. Sapolsky RM. Arch Gen Psychiatry 2000;57:925-935. 3. Sheline Y, et al. Am J Psychiatry 2003;160:1516-1518.

  46. Patients With Major Depressive Disorder (MDD) May Deny Emotional Symptoms • 50% of MDD patients in primary care settings complain of multiple unexplained somatic symptoms • 11% deny psychological symptoms in primary care settings Simon GE, et al. N Engl J Med 1999;341:1329-1335.

  47. Major Depressive Episodes (MDEs) Can Be Chronic and Recurrent Chance of Subsequent Major Depressive Episodes (%) • Graph adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:372.

  48. Definitions • Characteristics/Symptoms • Epidemiology • Comorbidity/Clinical course • Assessment/Evaluation • Treatment Options • SUICIDE UPDATE

  49. Clinically Significant Depressive Symptoms are Prevalent Among Primary Care Patients in the U.S. • 20.9% of primary care patients have clinically significant depressive symptoms • Only 1.2% of primary care patients cited depression as the reason for their visit Zung WW, et al. J Fam Pract 1993;37:337-344.

  50. Major Depressive Disorder (MDD) is Still Largely Untreated • Only 21.6% of all MDD patients in this study received adequate treatment. Patients with MDD in the last 12 months 51.6% of patients with MDD received some treatment 48.4% of patients with MDD did not receive any treatment 58.1 % of treated patients received inadequate treatment 41.9 % of treated patients received minimally adequate treatment Kessler RC, et al. JAMA 2003;289:3095-3105.

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