Bns 3 Exam - Mood Disorders In Children And Adolescence

Front 1

What disorders belong to MDD?

Back 1

MDD
DD
Dysthymic D
Bipolar (1, 2, NOS)
Cyclothymic D

Front 2

What is the MDD Etiology?

Back 2

2% children (ages 6-12)
4-8% adolescents (12-18 ages)
Male to Female ration 1:1 in childhood
M:F ratio in adolescence is 1:2
>70% of children under the age of 18 with DD or any MD DO NOT get diagnosed and treated!!!!!*****

Front 3

*** MDD and suicide in teenagers

Back 3

Any suicide attempt by a teenager need to be taken very seriously. *****

Front 4

_____% of of teens SERIOUSLY contemplate suicide

Back 4

20% (1:5)

Front 5

_____% ATTEMPT suicide

Back 5

8%

Front 6

3rd leading cause of death is suicide in ______

Back 6

15-24 yo
(1st is motorcycle accident, 2nd homicide)

Front 7

5th leading cause of death is suicide in _____

Back 7

5-14 yo

Front 8

Risk Factors for Suicidal Behavior

Back 8

• History of Prior attempts
• Substance use disorder
• Disruptive Behavior
• Impulsivity/Aggression
• Access to lethal means/agents
• Family History of suicide
• Exposure to negative life events

Front 9

Suicide Risk Assessment
Differentiate suicidal behavior from self injurious or self harming behavior

Back 9

 Self harm behaviors relieve negative affective states
 “Cutting” on body parts covered by clothing but can burn or do other acts of self mutilation. Need to releave some anxiety though cutting. Acts in rather than out. Due to physical and sexual abuse.

Front 10

passive vs active suicidal rhoughts

Back 10

Suicidal thoughts: passive: “I wish I was dead”,
active: Have a plan already, plan, intent – all need to be assessed

Front 11

MDD Diagnosis

Back 11

5+ symptoms present at least 2 weeks and one must be depressed mood or anhedonia
* Remember MSIGECAPS
. Rule out mixed episode (criteria met simultaneously for manic and depressed mood and qualifies as Bipolar Disorder)
• C. Distress, impairment caused.
• D. Rule out substance induced or GMC
• E. Rule out Bereavement

Front 12

What is MSIGECAPS stands for and used if for?

Back 12

MDD Diagnosis:
Mood – depressed
Sleep – too much or too little
Interest – diminished interest or pleasure
Guilty – ruminations, worthlessness
Energy – low or sense of fatigue
Concentration – low or indecisiveness
Appetite – high or low (wt loss or gain)
Psychomotor – agitation or retardation
Suicidal – thoughts of death +/- plan

Front 13

Bereavement

Back 13

 Within 2 mos of loss of a loved one.
 If greater than 2 mos s/p loss, consider MDD if marked impairment, morbid preoccupation with worthlessness, SI, psychotic symptoms, or PMR.

Front 14

MDD Clinical Presentation

Back 14

• Look for sx within appropriate developmental contexts.
• Children have fewer:
 Melancholic sx.
 Suicide attempts
 Delusional sx.

Front 15

MDD: Childhood Clinical Presentation

Back 15

• Irritability
• Low frustration tolerance
• Temper Tantrums
• Somatic Complaints (stomach ache, headache)
• Social Withdrawal
• “Acting Out”
• School Refusal
• Failure to make expected wt gain (FTT)

Front 16

MDD Adolescent Presentation

Back 16

• Anger (sometimes palpable)
• Academic difficulties
• Behavioral changes (Reckless, risk taking, hostile behavior)
• Social withdrawal
• Giving away valued possessions
• Frequent school absences

Front 17

MDD Comorbidities

Back 17

• 50-90 % of depressed kids have other psychiatric disorder
• 50% have 2 or more other psych. Disorders
• Most frequent comorbidities:
 ANXIETY
 Disruptive Behavior Dos (ODD or CD)
 ADHD
 Substance Use Disorders (self medicating?)

Front 18

MDD Differential Diagnosis Medical:

Back 18

• Medical
• Hypothyroidism (Check TSH, Free T3 and T4)
• Mononucleosis (Monospot)
• Anemia (CBC with diff)
• Cancers
• Autoimmune Disease (RA, Lymes)
• Premenstrual Dysphoric Disorder
• Bereavement

Front 19

Bereavement
If sx of MDD present within 2 mos of loss of loved one, we call it bereavement unless:

Back 19

• 1. Excessive guilt other than survivor guilt.
• 2. Thoughts of death other than to join loved one.
• 3. Morbid preoccupation with worthlessness.
• 4. Marked Psychomotor Retardation.
• 5. Prolonged functional impairment.
• 6. Hallucination other than thinking see/hear lost loved one.

Front 20

How to Rule out Bipolar Affective Disorder (BPAD)?

Back 20

• Look for significant FAMILY HISTORY
• Look for psychotic symptoms (depression with psychosis in the young usually foreshadows an eventual dx of BPAD)
• Look for any history of pharmacologically induced mania (i.e., unopposed antidepressant)
• Look for any history of HYPOmanic symptoms.

Front 21

MDD Course

Back 21

• Mean duration of episode is 8 mos.
• Most will recover from first episode.
• Recurrence: 20-60% by 1-2 years after remission and 70% by 5 years after remission
• Majority of children/teens diagnosed with MDD will have symptoms into adulthood.
• 20-40% will develop Bipolar Disorder (depressive episode is most usual index mood episode for those who go on to BPAD)

Front 22

MDD Poor Prognostic Factors

Back 22

• Greater severity of symptoms
• Multiple recurrent episodes
• Comorbidity
• Hopelessness
• Residual, subsyndromal symptoms
• Negative cognitive style
• Family problems
• Low SES
• Exposure to ongoing negative life events

Front 23

MDD Complications

Back 23

• Suicide
• Greater risk for:
 Substance abuse, nicotine dependence
 Legal problems
 Physical illness
 Early pregnancy
 Poor work and school functioning
 Psychosocial difficulties (peer and family relations)

Front 24

Depressive Disorder NOS

Back 24

Premenstrual Dysphoric Disorder, Minor Depressive Disorder

Front 25

Dysthymic Disorder

Back 25

Often overlooked, misdiagnosed.
Depressed, irritable mood most days for one year and 2+ sx:
“CHASSE” (Concentration poor, Hopelessness, Appetite up or down, Self esteem low, Sleep too much or too little, Energy low)

Front 26

What is “CHASSE” means and what is it for?

Back 26

Dysthymic disorder diagnosis
Concentration poor, Hopelessness, Appetite up or down, Self esteem low, Sleep too much or too little, Energy low

Front 27

MDD Treatment

Back 27

• Randomized Controlled Trials (RCTs) in adolescence show greater reduction in symptoms with combination therapy and antidepressant.
• No RCTs in clinically referred children (!)
• Multimodal Treatment
 Therapy
 Medication
 Family Therapy
 School/Learning Interventions
 Community Resource utilization

Front 28

MDD Pharmacotherapy

Back 28

• First Line: SSRIs
• Escitalopram is FDA approved for adolesent (12-18yo) depression
• Fluoxetine is approved for child and adolesent depression (8-18yo)
• Any SSRI can be used regardless of FDA approval – but I usually start with Fluoxetine (PROZAC).
• 30-40% remission rate on SSRI (between 2 wks and 2 mos of symptom reduction)
• Note: TCAs no better than placebo in kids. TCA DO NOT WORK IN KIDS!

Front 29

Clinical Use of SSRIs

Back 29

• Shorter half life so may need BID dosing
• Start low and go slow (with all meds for kids)
• Treat for 4 weeks minimum before increase in dose or switch.
• No response after 8 weeks, recommend alternative antidepressant (alternative SSRI, NDRI, SNRI)
• If partial response, augmentation strategy – Lithium (SE: weight gain), Bupropion, Mirtazapine

Front 30

Black Box Warning on SSRIs*****

Back 30

• In 2004, the FDA released a Black Box Warning on all SSRIs (and now on all classes of antidepressants) regarding suicidal thoughts and behaviors.
• No completed suicided in RCTs.
• Increase in “suicidal signal” i.e., thoughts and behaviors, from 2% in placebo arm to 4% in SSRI treated arm.
• Risk increased in individuals up to age 24. (tell them about suicidal thoughts)!!!!!

Front 31

Consequences of BBW on SSRIs

Back 31

• Positive correlation between use of SSRIs and decrease in adolescent suicide rate.
• SSRI Rx rates have declined by 25% since BBW introduced in 2004.
• CDC reported 14% suicide rate increase in 5-19 yo between 2003 and 2004.
• Note: Most depressed kids/teens are managed by PCPs. Be comfortable with what you Rx.
• Note: Risk Benefit ratio is still and always will be in favor of RX of SSRI for depressed kid/teen.**

Front 32

Serotonin Syndrome

Back 32

• Serotonin Discontinuation Syndrome seen when short half life SSRIs (paroxetine; SE: lots of weight gain) abruptly dc’d. Flu like sx, insomnia, rebound depression. None with fluoxetine, half life is 2 weeks.

Front 33

Suicide Risk Monitoring for MDD

Back 33

• Look for agitation, sleep disturbance, mania, SI in genral.
• FDA recommends:
 Weekly visits for first month
 Biweekly visits after first month
 RX smallest quantity allowed (one or two week supply) to avoid OD.
 Monitor signs above intensely for first few months of treatment.

Front 34

Bipolar I Disorder

Back 34

True manic + true depressive episodes: 1.6% of those under 18

Front 35

Bipolar II Disorder

Back 35

Hypomanic + major depressive episoded: 0.5%of those under 18

Front 36

What is the most overdiagnosed Disorder in kids?

Back 36

Bipolar disorder *****

Front 37

How do we dx BPAD in young?

Back 37

• Normal children can display some degree of manic or hypomanic behavior in context of situation (7yo on Christmas morning).
• Must consider how sx manifest across development since we are restricted to adult oriented DSM IV-TR criteria.
• Must obtain information from caregivers because child will have limited insight into illness. Accurate symptom report and change from baseline will only come from parent or caregiver.
A school age child will not drink to excess, drive recklessly, get put in jail for DUI or have promiscuous sex. However he may inappropriately touch himself or others, engage in wild stunts in play that are reckless and potentially hazardous

Front 38

Criteria for Manic Episode

Back 38

Episode:
 Elevated, expansive or irritable mood for at least 7 days (can be less if hospitalization required)
 3+ of following, 4+ if mood is “irritable”
 Distractibility
 Insomnia
 Grandiosity
 Flight of Idea
 Activities – increased goal directed
 Speech fast or pressured
 Thoughtlessness – poor judgment, high risk taking
 (Think “DIG FAST”)

Front 39

Criteria for Hypomanic Episode

Back 39

• Elevated, expansive or irritable for 4 days
• 3+ sx of DIGFAST if elevated or expansive
• 4+ sx of DIGFAST if irritable
• Unequivocal change in fxn from baseline that is uncharacteristic of person when not hypomanic
• Disturbed mood and change in fxn is observable by others (not just subjective report).
• Does NOT cause marked distress or impaired fxn. ***
• Rule out Substance Induced or GMC.
• Note: If mania or hypomania caused by med, light therapy or ECT it is not to be counted towards dx of BPAD.

Front 40

BPAD in Kids and Teens

Back 40

• Most often present with mixed episodes.
• Frequently irritable, explosive, angry.
• Manic kids (<12 yo) have “rage attacks” and “affective storms”.
• Extreme age inappropriate irritability in kids.
• Hypomania more common in >12yo, rare in kids. Note, can not need hospitaliztion in hypomania.
• BP Depressed kids: anger, dysphoria, more common comorbidities of conduct, anxiety, SUD.

Front 41

BPAD Comorbidities

Back 41

• 50-80% have ADHD (!)
• 20-60% have Disruptive Behavior Disorder
• 30-70% have Anxiety Disorder

Front 42

BPAD DDx

Back 42

• ADHD
• DBD (ODD, CD)
• Unipolar Depression
• SUD
• PDD
• Schizophrenia
• Borderline Personality Disorder (controversial)

Front 43

Suspect Bipolar in a child with ADHD IF:

Back 43

 1.ADHD sx appear >10yo (criteria says <7yo)
 2. ADHD sx that appear abruptly in ow healthy kid.
 3. ADHD sx initially responding to meds, now not.
 4. ADHD sx come and go and occur with mood chgs.
 5. Child with ADHD begins to have: elation, grandiosity, depression, no need for sleep, sexual behavior.
 6. ADHD kid with severe mood swings, temper tantrums, rages.
 7. ADHD kid develops psychosis.
 8. Strong family hx of BPAD especially in child not responding to trx for ADHD.
******Note: Can and often DO have both diagnoses.

Front 44

Bipolar Disorder NOS

Back 44

• Being researched
• Hallmark is emotional dysregulation
• Does not meet necessary time criteria for BP I or BP II
• Will hear of ultradian, ultra rapid, and rapid cycling versions.
 Ultradian: Mood polarity shifts within same day
 Ultra rapid: Mood polarity shift every couple days
 Rapid cycling: In DSM IV-TR means 4 mood polarity changes in one year – but often used incorrectly instead of one of the above 2 terms even by seasoned clinicians.

Front 45

What is the Hallmark of BPAD NOS?

Back 45

emotional dysregulation

Front 46

define Ultradian

Back 46

Mood polarity shifts within same day in a BPAD NOS

Front 47

define Ultra rapid

Back 47

Mood polarity shift every couple days

Front 48

define Rapid cycling

Back 48

In DSM IV-TR means 4 mood polarity changes in one year – but often used incorrectly instead of one of the above 2 terms even by seasoned clinicians.

Front 49

Genetics of BPAD
Why is FAMILY HX so important?

Back 49

 Prevalence of BPAD in first degree relatives of adults with BPAD is 8-10x higher than average population.
 5.4 to 15% lifetime prevalene of BPAD in child of bipolar pareent (compared to less than 1% in control)
 Children with BPAD parent at higher risk to develop:
• BPAD
• Depression
• Anxiety
• ADHD
• Behavior problems
• First degree relatives of BPAD pts have higher rates of mood disorders.

Front 50

Bipolar Disorder Treatment

Back 50

• Medication
• Educational Intervention
• Psychotherapy
• Meds treat Mania, Mixed, Depressive Episodes
• Acute Phase – to response
• Maintenance Phase – to Remission and beyond.
• (Response: Reduction in Symptoms 2wks to 2 mos, Remission: Greater than 2 mos.)

Front 51

• Acute Mania treatment

Back 51

 Mood Stabilizer or AAP

Front 52

• Acute Mania with Psychosis treatment

Back 52

 AAP + Mood Stabilizer.

Front 53

• Acute Depression treatment

Back 53

 Stabilize Mood then add SSRI or Bupropion (anecdotally least likely to cause manic or hypomanic switch). SSRI higher risk activation in kids with BPAD.
 Consider Lamotrigine (FDA approved for BP depression but higher risk SJS/TEN in kids). Shed the skin.

Front 54

Mood Stabilizers/AAPS****

Back 54

• Mood Stabilizers:
 Lithium
 Valproate
 Carbamazepine
 Lamotrigine
• AAPs : Remember Metabolic Syndrome
 Olanzapine, Risperidone, Quetiapine, Aripiprazole, Ziprasidone, Asenapine
 Metabolic Syndrome: Increased risk significant weight gain, hyperlipidemia, Type II diabetes; less likely with Aripiprazole and Ziprasidone.

Front 55

Valproate can cause

Back 55

hepatic failure, thrombocytopenia, and PCOS. Also not a choice in adolescent female who is sexually active – major teratogen (Neural Tube Defects)

Front 56

Carbamazepine induces

Back 56

its own metabolism so have to monitor levels regularly and expect to increase dose serially even once therapeutic level achieved.

Front 57

Lamotrigine causes

Back 57

rash in 10% of those who take it. Rarely goes on to SJS or TEN but can

Front 58

Topiramate, Gabapentin

Back 58

– no proof they do anything. DON’T GIVE IT TO ANYBODY!!!!

Front 59

List the 2 Psychotherapy for BPAD

Back 59

• CBT – Cognitive Behavioral Therapy
• Interpersonal Therapy

Front 60

Psychotherapy for BPAD
• CBT – Cognitive Behavioral Therapy

Back 60

• CBT – Cognitive Behavioral Therapy
 First line therapy in most mood disorders (depression, anxiety, bipolar disorder)
 Focus on how thoughts, feelings, and actions are triangularly related.
 Focus on challenging automatic thoughts and replacing with more rational productive thoughts.
 Focus on problem solving and coping skills.

Front 61

Psychotherapy for BPAD
• Interpersonal Therapy

Back 61

• Interpersonal Therapy
 Manualized like CBT
 Adolescent format available
 16 sessions
 4 Areas evaluated and worked on:
• Interpersonal disputes
• Interpersonal deficits
• Role transitions
• Grief
• Other therapies: Family, Beh Mod, Dialectical Beh. Therapy

Front 62

Majority suicide attempts through ______

Back 62

overdose

Front 63

Over half of all suicide completions due to _____

Back 63

firearm

Front 64

What id DIG FAST stands for and what do you use it for?

Back 64

Evaluate Maniac episode
 Distractibility
 Insomnia
 Grandiosity
 Flight of Idea
 Activities – increased goal directed
 Speech fast or pressured
 Thoughtlessness – poor judgment, high risk taking