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85 Cards in this Set

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Although suicidal thoughts and behaviors can occur in the context of a depressive disorder, most youth who contemplate, attempt, or complete suicide (are or are not) in the midst of a major depression.
NOT

it is not clear that optimal treatments for depression mitigate the risks of suicidality among youth in general.
Mood disorders among children and adolescents have been increasingly recognized over the last three decades, and evidence suggests that ? may have the greatest efficacy.
combined treatment modalities, including medication and cognitive-behavioral strategies,
mood-congruent auditory hallucinations, somatic complaints, withdrawn and sad appearance, and poor self-esteem

age?
Young, depressed children commonly show symptoms that appear less often as they grow older, including mood-congruent auditory hallucinations, somatic complaints, withdrawn and sad appearance, and poor self-esteem.
pervasive anhedonia,
severe psychomotor retardation, delusions, and
a sense of hopelessness

age
Symptoms that are more common among depressed youngsters in late adolescence than in young childhood are pervasive anhedonia, severe psychomotor retardation, delusions, and a sense of hopelessness
Symptoms that appear with the same frequency, regardless of age and developmental status, include
suicidal ideation, depressed or irritable mood, insomnia, and diminished ability to concentrate.
(few, some, many, most) young children with major depressive disorder have histories of abuse or neglect.
MOST
he rate of major depressive disorder in preschoolers is
?
RARE <1%
Among prepubertal school-age children in the community, the point prevalence is approximately ? percent
1%
gender bias in school age children regrading depression
same, perhaps >in boys
teen rates of mDD?
gender bias in teens?
1 to 6%
girls double of boys
Estimates of cumulative prevalence of depression among older adolescents range between ? percent
14 and 25
Reported rates of dysthymic disorder are generally lower than those of major depressive disorder, with rates of ? in prepubertal children compared with ? percent for major depressive disorder
Reported rates of dysthymic disorder are generally lower than those of major depressive disorder, with rates of 5 of 100,000 in prepubertal children compared with 1 percent for major depressive disorder
In adolescents, as in adults, dysthymic disorder is reported to occur in about ? adolescents compared with about ? percent for major depressive disorder.
In adolescents, as in adults, dysthymic disorder is reported to occur in about 5 of 1,000 adolescents compared with about 5 percent for major depressive disorder.
Among hospitalized children and adolescents, the rates of major depressive disorder are much higher than in the general community; of these, as many as ? percent of children and ? percent of adolescents are depressed
Among hospitalized children and adolescents, the rates of major depressive disorder are much higher than in the general community; of these, as many as 20 percent of children and 40 percent of adolescents are depressed
Two genes have been identified as incurring vulnerability for depressive disorder.
MAOA
serotonin transporter gene
Serotonin transporter ... which allele most associated and least associated with depression?
SS most (less efficient in transcription)
LL least
having one depressed parent probably ? the risk for offspring. Having two depressed parents probably ? the risk of a child having a mood disorder before age 18 compared with the risk for children with two unaffected parents
having one depressed parent probably doubles the risk for offspring. Having two depressed parents probably quadruples the risk of a child having a mood disorder before age 18 compared with the risk for children with two unaffected parents
prepubertal children in an episode of depressive disorder secrete significantly more ? during sleep than do normal children and those with nondepressed mental disorders
growth hormone
These children also secrete significantly (less or more) growth hormone in response to insulin-induced hypoglycemia than do nondepressed patients.
LESS
cortisol hypersecretion in children with depression ... what the evidence?
mixed
What do polysomnographs show for childhood depression?
Polysomnography shows either no change or changes characteristic of adults with major depressive disorder:
reduced rapid eye movement (REM) latency and

an increased number of REM periods.
Magnetic resonance imaging (MRI) scans in more than 100 psychiatrically hospitalized children with mood disturbances report a ??
How does that compare with adults?
low frontal lobe volume and a high ventricular volume

These results are consistent with MRI findings in adults with major depression insofar as postmortem studies of depressed adults have demonstrated selective loss of frontal lobe cells and frontal lobe serotonin.
Damage to the ? lobes has also been associated with depressive symptoms in patients after stroke
fronta
Thyroid hormone studies have found ? levels in depressed adolescents than in a matched control group.

What about TSH values?
lower free total thyroxine (FT4)

These values were associated with normal thyroid-stimulating hormone (TSH).
Evidence indicates that boys whose fathers died before they were ? years of age are at greater risk than controls to develop depression
13
.
The psychosocial impairment that characterizes depressed children lingers far after recovery from the index episode of depression
These deficits can be compounded by the relatively long duration of at least 1 year for a dysthymic episode and an average of ? months to ? for a depressive episode
9 to 12months
A major depressive episode in a prepubertal child is likely to be manifest by
somatic complaints,
psychomotor agitation, and
mood-congruent hallucinations.
Sx more common in teens and adults?
anhedonia
hopelessness
psychomotor retardation
delusions
sx perhaps unique to teens
Feelings of restlessness, grouchiness, aggression, sulkiness, reluctance to cooperate in family ventures, withdrawal from social activities, and a desire to leave home are all common in adolescent depression. School difficulties are likely. Adolescents may be inattentive to personal appearance and show increased emotionality, with particular sensitivity to rejection in love relationships.
Mood disorders tend to be chronic if they begin early. Childhood onset may be the most severe form of mood disorder and tends to appear in families with
a high incidence of mood disorders and
alcohol abuse
childhood depression delusion themes?
. Depressive delusions center on themes of guilt, physical disease, death, nihilism, deserved punishment, personal inadequacy, and (sometimes) persecution.
Dysthymic disorder in children is known to have an average age of onset that is several years ? than the age of onset of major depressive disorder.
earlier
Bereavement time criteria in children?
same as adults, 2 months
The mean length of an episode of major depression in children and adolescents is about ? months; the cumulative probability of recurrence is ? percent by 2 years and ?percent by 5 years.
The mean length of an episode of major depression in children and adolescents is about 9 months; the cumulative probability of recurrence is 40 percent by 2 years and 70 percent by 5 years.
Follow-up studies have found that in ? percent of adolescents who have a major depression, bipolar I disorder will develop in a period of 5 years after the index depression
20 to 40%
Clinical characteristics of the depressive episode that suggest the highest risk of developing bipolar I disorder include
delusionality and
psychomotor retardation in addition to a
family history of bipolar illness.
Dysthymic disorder has an even more protracted recovery than major depression; the mean episode length is about ? year
4
Early-onset dysthymic disorder is associated with significant risks of comorbidity with major depression (? percent), bipolar disorder (? percent), and eventual substance abuse (? percent).
Early-onset dysthymic disorder is associated with significant risks of comorbidity with major depression (70 percent), bipolar disorder (13 percent), and eventual substance abuse (15 percent).
The risk of suicide, which represents ? percent of mortalities in the adolescent age range, is significant among adolescents with depressive disorders.
12
This recent investigation, Treatment for Adolescents with Depression Study (TADS) Team (2004) divided the 439 adolescents, between the ages of 12 and 17 years, into three treatment groups of 12 weeks, composed of either
fluoxetine (Prozac) alone (10 to 40 mg per day),
fluoxetine with the same dose range in combination with CBT,
or CBT alone
Based on ratings of the Children's Depression Rating Scale-Revised (CDRS-R) and clinical global ratings, the group of depressed adolescents receiving the? treatment had significantly superior response rates compared with ?
combination

either treatment alone
Based on clinical global improvement, rates of much or very much improvement were ? percent for the group that received the combined treatment, ? percent for the group that received fluoxetine, and ? percent for the CBT alone. The placebo group had a ? percent response rate.
Based on clinical global improvement, rates of much or very much improvement were 71 percent for the group that received the combined treatment, 61 percent for the group that received fluoxetine, and 43 percent for the CBT alone. The placebo group had a 35 percent response rate.
rates of suicidal thinking and behaviors were ? percent for patients on placebo, versus ?percent among child and teen patients on antidepressant medications.
2 vs 4
? is currently the only antidepressant that has FDA approval in the treatment of depression in children and adolescents.

Drugs with RCT data in MDD children?
Fluoxetine

Fluoxetine, Citalopram and Sertaline
Recommended duration of tx for children and adolescents for MDD with Rx?
1 year and then stop if good response
and reduce during low stress period
Reports indicate that as many as ? of suicidal individuals express suicidal intentions to a friend or a relative within 24 hours before enacting suicidal behavior.
50%
The most common method of completed suicide in children and adolescents is ?
which accounts for about ? of all suicides in boys and almost one ? of suicides in girls.
the use of firearms,

which accounts for about two thirds of all suicides in boys and almost one half of suicides in girls.
2nd, 3rd most common forms of suicide?
hanging
CO poisoning
Additional risk factors in suicide include
a family history of suicidal behavior,
exposure to family violence, impulsivity,
substance abuse, and
availability of lethal methods.
Suicide rates in 2000 among boys and girls 10 to 14 years of age were ? and ? per 100,000, whereas among late adolescent boys and girls the rates increased to ? and ? per 100,000.
Suicide rates in 2000 among boys and girls 10 to 14 years of age were 2.3 and 0.6 per 100,000, whereas among late adolescent boys and girls the rates increased to 13.2 and 2.8 per 100,000.
Large surveys indicate that, although up to ? percent of high school students in the United States have experienced suicidal ideation, and ? percent have exhibited suicidal behaviors, only about ? percent of adolescents who attempt suicide come to medical attention.
Large surveys indicate that, although up to 20 percent of high school students in the United States have experienced suicidal ideation, and 10 percent have exhibited suicidal behaviors, only about 2 percent of adolescents who attempt suicide come to medical attention.
In the last 15 years, the rates of both completed suicide and suicidal ideation rates have ?increased on decreased?.
In the last 15 years, the rates of both completed suicide and suicidal ideation rates have decreased.
The rates for suicide depend on age, and they increase significantly after puberty. Whereas less than ? per 100,000 completed suicide occurs in persons younger than 14 years of age, about ? per 100,000 completed suicides occur in adolescents between 15 and 19 years of age. In adolescents younger than 14 years of age, suicide attempts are at least ? times more common than suicide completions. Between 15 and 19 years of age, however, the rate of suicide attempts is about ? times greater than the rate of suicide completions.
The rates for suicide depend on age, and they increase significantly after puberty. Whereas less than 1 per 100,000 completed suicide occurs in persons younger than 14 years of age, about 10 per 100,000 completed suicides occur in adolescents between 15 and 19 years of age. In adolescents younger than 14 years of age, suicide attempts are at least 50 times more common than suicide completions. Between 15 and 19 years of age, however, the rate of suicide attempts is about 15 times greater than the rate of suicide completions.
The number of adolescent suicides over the past several decades has
tripled or quadrupled.
Universal features in adolescents who resort to suicidal behaviors are
the inability to synthesize viable solutions to ongoing problems

and the lack of coping strategies to deal with immediate crises
Completed suicide and suicidal behavior is ? times more likely to occur in individuals with a first-degree family member with similar behavio
two to four
Low levels of ? have been found postmortem in the brains of persons who completed suicide
serotonin and its major metabolite, 5-hydroxyindoleacetic acid (5-HIAA),
Low levels of 5-HIAA have been found in the cerebrospinal fluid of depressed persons who attempted suicide by ?
violent methods
Although major depressive illness is the most significant risk factor for suicide, increasing its risk by ? percent, many severely depressed individuals are not suicidal.
20%
Various features, including a sense of
hopelessness,
impulsivity,
recurrent substance use, and a
history of aggressive behavior, have been associated with an increase risk of suicide
Large community studies have provided data suggesting that sexual orientation is a risk factor, with increased rates of suicidal behavior of ? times among youth who identify themselves as gay, lesbian, or bisexual
two to six
The characteristics of adolescents who attempt suicide and those who complete suicides are similar and as many as ? percent of suicidal persons have made a previous attempt
40%
Depression alone is a more serious risk factor for suicide in ? than in ? gender
girls than boys
The profile of an adolescent who commits suicide is occasionally
one of high achievement and perfectionistic character traits; such an adolescent may have been humiliated recently by a perceived failure, such as diminished academic performance.
About ? percent of youthful persons who complete suicide had previous psychiatric treatment, and about ? percent had made a previous suicide attempt.
About 40 percent of youthful persons who complete suicide had previous psychiatric treatment, and about 40 percent had made a previous suicide attempt.
One recent study investigated two clusters of teenage suicide in Texas. The researchers found that indirect exposure to suicide through the media was or was not significantly associated with suicide.

Factors that were associated included
WAS NOT

previous suicidal threats or attempts,

self-injury,

exposure to someone who had died violently,

recent romantic breakups,

and a high frequency of moves and changes in schools attended and parental figures lived with.
Persons at high risk of suicide include
those who have made previous suicide attempts;

boys older than 12 years of age with histories of aggressive behavior or substance abuse;

those who have made an attempt with a lethal method, such as a gun or a toxic ingested substance;

those with major depressive disorder characterized by social withdrawal, hopelessness, and a lack of energy;

girls who have run away from home, are pregnant, or have made an attempt with a method other than ingesting a toxic substance;

and any person who exhibits persistent suicidal ideation.
Difference between teen and adult mania?
usually adult is mania after depression
while teen can be mania acute onset with delusions (grand/paranoid) and hallucinations
Psychotic features greater in teens
In adolescents with major depressive disorder destined for bipolar I disorder, those at highest risk have
family histories of bipolar I disorder and
exhibit acute, severe depressive episodes with
psychosis,
hypersomnia, and
psychomotor retardation.
Epidemiologic studies in older adolescents have reported lifetime prevalence of bipolar I and II disorders to be approximately ? percent. A recent epidemiologic survey of current illness in children under 13 years of age found ? cases of classic bipolar illness.
Epidemiologic studies in older adolescents have reported lifetime prevalence of bipolar I and II disorders to be approximately 1 percent. A recent epidemiologic survey of current illness in children under 13 years of age found no cases of classic bipolar illness.
Among adults with bipolar disorder, the 20 to 30 percent who exhibit “mixed mania,” are most likely to have
a chronic course,
absence of discrete episodes,
higher risk of suicidal behavior,

onset of the disorder in childhood and adolescence,

neuropsychological features similar to children with ADHD, and

show a poorer response to treatment
Family studies consistently demonstrate that offspring of a parent with bipolar I disorder have a ? percent chance of having a mood disorder, and offspring of two parents with bipolar disorder have a ? percent risk of developing a mood disorder.
25%

50 to 75
In first-degree relatives of children with bipolar disorder, ADHD occurs with the same rate as in ?
first-degree relatives of children with ADHD only
i.e., > than general pop
results suggest that childhood bipolar disorder may be distinguished as a subtype of bipolar disorder that emerges in children whose family histories are heavily loaded for
bipolar disorder and psychiatric comorbidities, such as ADHD.
Bipolar Ds in children ... show grey or white matter changes?
increasing white matter
The few studies with children with bipolar disorder suggest a dysfunction in neural circuitry in the
amygdala, striatal, thalamic, and prefrontal structures of the brain
A growing body of evidence suggests that children and adolescents with bipolar disorder make a greater number of ? errors
emotion recognition
One of the main sources of diagnostic confusion regarding children with early-onset bipolar disorder is the comorbid ?, which is present in 60 to 90 percent of them
ADHD
Rates of comorbid conduct disorder have been found to range from 48 to 69 percent among children and adolescents with bipolar disorder. J. Biederman found that the two manic symptoms more common in the comorbid group than the bipolar only group were
physical restlessness and poor judgment.
Children and adolescents with bipolar disorder have been reported to have higher than expected rates of panic and other anxiety disorders. Lifetime prevalence of panic disorder was found to be ? percent among subjects with bipolar disorder compared with ? percent in those without mood disorders
Children and adolescents with bipolar disorder have been reported to have higher than expected rates of panic and other anxiety disorders. Lifetime prevalence of panic disorder was found to be 21 percent among subjects with bipolar disorder compared with 0.8 percent in those without mood disorders
A recent longitudinal study of 263 child and adolescent inpatients and outpatients with bipolar disorders followed for an average of 2 years found that approximately ? percent recovered from their index episode within that period.

? of these patients had at least one recurrence of a mood disorder during this time, more frequently a depressive episode than a mania
70%

50%
Rapid Cylcing predictors?
Predictors of more rapid cycling included lower socioeconomic status (SES), presence of lifetime psychosis, and bipolar disorder not otherwise specified diagnosis
What seems more stable BP1 or 2?
1
All of the existing longitudinal literature on bipolar disorders in early childhood has found that when the illness emerges in young children, recovery rates are

Also, a greater likelihood is seen of in early onset vs late teen/adult onset
LOWER

MIXED
Rapid Cycyling
Polarity changes
In addition to managing manic and depressive symptoms in early-onset bipolar disorder, most children with bipolar disorder are likely to need treatment for comorbid ADHD. Chart reviews indicate that treatment of ADHD is significantly more successfully achieved (before or after) mood stabilization is accomplished.
AFTER