Mood Disorders Children and Adolescents - PowerPoint PPT Presentation

1 / 112
About This Presentation
Title:

Mood Disorders Children and Adolescents

Description:

Mood Disorders Children and Adolescents Waqar Waheed, MD FRCPC, DABPN Department of Psychiatry University of Calgary – PowerPoint PPT presentation

Number of Views:228
Avg rating:3.0/5.0
Slides: 113
Provided by: ITS1370
Category:

less

Transcript and Presenter's Notes

Title: Mood Disorders Children and Adolescents


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-Adrena
    l 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) to 45 (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

51
Other Investigations
  • MRI Head
  • Not indicated in the absence of focal
    neurological signs.

52
EEG/Sleep Study
  • To assess for seizure disorder if there is
    clinical suspicion

53
Prognosis
54
  • Greater symptom severity and the presence of
    co-morbidity are predictors of a poorer prognosis

55
  • The mean duration of a untreated Major Depressive
    Episode is 9 months

56
  • For untreated Dysthymic Disorder, the mean
    duration is 4 years

57
  • 18 month rate of recurrence for patients
    noncompliant with successful medication treatment
    is 90 (38 in med-comlian

58
Treatment Modalities
  • Setting
  • Psychotherapy
  • Medications

59
Other Modalities
  • ECT
  • Light Therapy
  • Transcranial Deep Brain Stimulation
  • Vagal Nerve Stimulation

60
Psychotherapy
  • Supportive Therapy
  • Cognitive-Behavioral Therapy
  • Interpersonal Psychotherapy

61
Cognitive-Behavioral Therapy
  • CBT is based on the cognitive triad negative
    thoughts about the self, the world, and the future

62
Supportive Psychotherapy
  • Maintain/improve self-esteem
  • Minimize/prevent symptom recurrence
  • Maximize patients adaptive capacities
  • The most widely practiced form of individual

63
Interpersonal Psychotherapy
  • IPT aims to intervene specifically in social
    functioning with consequent benefits in symptom
    experience. (for 12 and older)

64
IPT-A
  • Patient's social functioning problems are
    conceptualized as one or more of four areas

65
  • Interpersonal Disputes (relationship conflict)
  • Role Transitions (puberty, new school, new
    family)
  • Grief (death of a loved one)
  • Interpersonal Deficits (social/communication
    skills)

66
Other Forms of Therapy
  • Group Therapy
  • Family Therapy
  • Play Therapy

67
(No Transcript)
68
MEDICATION MANAGEMENT OFDEPRESSIVE DISORDERS
69
SSRI treatment
  • Fluoxetine - FDA approved for depression in
    children and adolescents
  • Escitalopram - FDA approved for depression in
    adolescents
  • Recent meta-analysis indicates a NNT of 6 for
    fluoxetine, 10 for other SSRIs in adolescent
    depression (Bridge et al 2007)

70
Other treatments
  • There is evidence for the use of venlafaxine
    (Emslie et al 2007) and bupropion in the
    treatment of adolescent depression (Daviss 2008).
  • TCAs have been shown to be of benefit in child
    and adolescent depression (Hazell et al 2006) but
    their use continues to be limited by the a/e,
    toxicity profiles.

71
SSRIs and Suicidality
  • Two meta-analyses (Bridge et al 2007, Hammad et
    al 2006) found an increase of 1 to 3
    spontaneously reported suicidal adverse events
    per 100 youth treated with SSRIs
  • The adverse event included increases in suicidal
    ideation (majority) and attempts at suicide (less
    commonly) with no completed suicides

72
SSRIs and Suicidality
  • The NNH was 112
  • Given the NNT of 10, nearly 11 times the number
    of adolescents would respond favorably than might
    spontaneously report suicidality
  • Suicide rates went up following a decline in the
    use of SSRIs due to the black box warning
    (Gibbons et al 2006, 2007 Libby et al 2007)

73
Other adverse effects
  • GI
  • Headache
  • Insomnia/hypersomnia
  • Jitteriness/tremulousness
  • Decreased sexual drive
  • Behavioral activation (8) usually within 7-10
    days, mgmt is to switch med
  • Onset of mania (2-3) usually in 2-3 weeks,
    switch med, consider mood stabilizer

74
Side Effects
75
Indications
  • Mild depressive illness? supportive psychotherapy
  • For moderate to severe depressive illnesses
    (having more than the minimal number of
    diagnostic criteria) or non-responders to brief
    supportive therapy ? consider SSRI, CBT/IPT or a
    combination.

76
Dosing
  • Prozac usually 10 mg x 1 week then 20 mg,
    re-evaluate in 4-6 weeks, if no response, change
    to 30-40 mg
  • Escitalopram, similar except at half the dosages

77
Psychotic Depression
  • Augment SSRI with an antipsychotic until
    psychosis stable, then taper and discontinue the
    antipsychotic while maintaining antidepressant med

78
  • Should be continued for at least 6 months after
    complete symptom remission

79
Treatment-resistant depression
  • Treatment-resistant depression is defined as
    failure of at least two adequate antidepressant
    drug trials of at least 810 weeks' duration,
    each at a therapeutic dose and serum level (if
    available) without even mild improvement
  • (American Academy of Child and Adolescent
    Psychiatry 2004 Ghaziuddin et al. 1996 Kutcher
    and Robertson 1995 Walter and Rey 1997).

80
TRD
  • Optimization (extending the initial medication
    trial and/or adjusting the dose adding CBT or
    IPT)-usually used if there has been partial
    response
  • Switching to another agent in the same or a
    different class of medications, augmentation, or
    a combination (e.g., lithium, triidothyronine)
    (Hughes et al. 2007) usually used if no
    response or unable to tolerate
  • No studies have validated these practices in
    children.

81
TRD
  • Finally, the use of somatic therapies that have
    not been well studied in children, such as
    transcranial magnetic stimulation, or more
    intensive somatic therapies for depressed teens,
    such as ECT, should be considered

82
(No Transcript)
83
Light Therapy
  • Typically used for the treatment of Seasonal
    Affective Disorder
  • and of delayed sleep phase disorder (DSPD)

84
  • 20-30 minutes each morning during the fall,
    winter and early spring months
  • Symptom relief within one to two weeks of regular
    use

85
Electro-Convulsive Therapy
  • May be used for adolescents

86
  • The principal adverse effect of ECT is
    anterograde and retrograde memory impairment
  • Used for refractory depression/mania or psychotic
    depression

87
Transcranial Magnetic Stimulation
  • TMS is a procedure in which electrical activity
    in the brain is influenced by a pulsed magnetic
    field

88
Types of TMS
  • Single-pulse TMS (diagnostic and research
    applications)
  • Paired-pulse TMS (used to evaluate cortical
    excitability)
  • Repetitive TMS (rTMS) has been used in
    therapeutic applications because it is capable of
    producing rapid bursts of pulses lasting
    approximately 60 seconds
  • An advantage of the rTMS procedure in the
    clinical setting is that no anesthesia is needed.
  • (Curra et al. 2002 Quintana 2005)

89
(No Transcript)
90
rTMS Research in adolescent depression
  • Adjunctive rTMS treatment in a prospective open
    label study in 8 adolescents demonstrated benefit
    (Wall et al 2011)
  • Two small case series (totaling nine subjects)
    have reported on the use of rTMS in adolescent
    depression (Loo et al. 2006 Walter et al. 2001).

91
rTMS Adverse Effects
  • Tension headaches reported in one patient were
    the only adverse effects noted from the rTMS
    procedure
  • (Walter et al. 2001)
  • Neuropsychological testing revealed no cognitive
    side effects after the course of rTMS was
    completed
  • (Loo et al. 2006).

92
Deep Brain Stimulation
  • Deep brain stimulation (DBS) is a neurosurgical
    procedure
  • Stimulation electrodes are chronically implanted
    into specific areas of the brain
  • An implanted, externally programmable pacemaker
    delivers high-frequency electrical pulses.
  • The site of electrode placement differs depending
    on the disorder to be treated.

93
DBS
  • DBS is currently approved for generalized
    dystonia in children 7 years and older. Its place
    in psychiatry is presently unclear.
  • DBS is considered an experimental procedure in
    children and adolescents with psychiatric
    disorders.

94
Vagal Nerve Stimulation
  • In July 2005, the VNS Therapy System was
    approved by the FDA for depression patients who
    have run out of treatment options
  • No studies to date in use for children/adolescents
    with mood disorders

95
MEDICATION MANAGEMENT OFBIPOLAR DISORDERS
96
(No Transcript)
97
Medications Bipolar Disorders
  • Lithium Carbonate (2 RCTs)
  • Valproic Acid (2 RCTs)
  • Carbamazepine (open label)
  • Atypical Antipsychotic Medications (1 RCT for R,
    O, S, A and Z)

98
General Considerations
  • FDA approved medications
  • Risperidone/Aripiprazole (10 yo)
  • Lithium Co3 (12 yo)
  • Olanzapine (13 yo)

99
  • Blood levels are monitored for Lithium, Valproic
    acid and Carbamazepine

100
  • Onset of action usually within the first week of
    treatment
  • (most RCTs were 3 weeks in duration)

101
Pharmacogenetics of CBZ
  • CBZ places individuals with HLA B1502 allele at
    high risk of SJ Syndrome
  • These patients may continue if identified 1-2
    months after initiation of treatment.
  • Absence of allele does not preclude risk of SJ
    Syndrome

102
Side Effects
103
Monitoring
  • In addition to clinical evaluation, lab tests are
    usually recommended periodically to assess for
  • Blood Levels of Medication
  • Bone Marrow Function
  • Liver/Pancreas Function
  • Thyroid Function
  • Kidney Function/Electrolyte levels
  • ECG

104
Types of Antipsychotic Medications
105
Mechanism of Action
  • Both types of antipsychotics block Dopamine
    receptors
  • The defining feature of the atypical
    antipsychotics is that they also block Serotonin
    receptors.

106
Common Side Effects
  • Sedation
  • Weight Gain
  • EPS (parkinsonism, akathisia, dystonia)-managed
    with anticholinergic meds
  • Metabolic Syndrome
  • Dyslipidemia
  • Impaired glucose tolerance
  • BP elevation/ Central adiposity

107
Uncommon Side Effects
  • Neuroleptic Malignant Syndrome
  • Heat Stroke
  • Tardive dyskinesia
  • Seizures
  • Heart Rhythm disturbance

108
Monitoring
  • In addition to clinical evaluation (including
    weight and blood pressure assessment), lab tests
    used for monitoring including
  • Fasting blood sugar
  • Cholesterol levels
  • Liver functions
  • Electrocardiogram

109
Abuse Potential
  • Although not as common as with medications such
    as Ritalin, Dexedrine or benzodiazepines, the
    antipsychotic medication Seroquel (street name
    Qwell, Susie Q) has been increasingly
    identified as a substance of abuse
  • (Pinta et al 2007, Waheed et al 2005, Wirshing
    et al 2004)

110
Treatment Resistant Bipolar Disorder
  • For bipolar disorder, failure of at least one
    antipsychoticmood stabilizer/antidepressant
    combination treatment trial of at least 6 weeks'
    duration without even mild improvement is
    considered evidence for treatment refractoriness
  • (American Academy of Child and Adolescent
    Psychiatry 2004 Kutcher and Robertson 1995
    Walter et al. 1999).

111
Treatment for Bipolar Depression
  • Lithium CO3
  • Lamotrigine
  • They have both demonstrated benefit either as
    monotherapy or as adjunctive treatment in open
    label studies

112
Questions/Comments?
  • Waqar.Waheed_at_albertahealthservices.ca
Write a Comment
User Comments (0)
About PowerShow.com