Download CHILDHOOD DEPRESSION: SIGNS, SYMPTOMS AND SOLUTIONS

PEDIATRIC AND ADOLESCENT
DEPRESSION
DIAGNOSIS AND TREATMENT
ANTOINETTE FALK, M.D.
Solo Private Practice
Psychiatry
COURSE OBJECTIVES
To identify the unique manifestations of
depression in adolescents, as opposed to those
seen in adults
 To know the medical and psychiatric
comorbidities of untreated depression
 To become familiar with proper treatment
approaches and modalities in treating depression
 To understand and appreciated the need for early
intervention and neuroprotection.

HISTORICAL PERSPECTIVE
 Depression
(melancholia) in childhood
reported in 1800’s
 Prior to 1960’s, believed that depression
could not develop due to immature
superego construction.
 In 1970 an international congress
concluded childhood depression to be
significant
MAJOR DEPRESSIVE EPISODE
DSM-IV CRITERIA
Presence of 5 symptoms during the same 2 week
period:
 Depressed or irritable mood
 Diminished interest or loss of pleasure in almost
all activities (Anhedonia)
 Sleep disturbance – initial, middle or terminal
insomnia
 Weight change or appetite disturbance (failure to
achieve expected weight gain or 5% loss of body
weight in 1 month)

MAJOR DEPRESSIVE EPISODE
DSM-IV CRITERIA - CONTINUED
Decreased concentration or indecisiveness
 Suicidal ideation or thoughts of death
 Psychomotor agitation or retardation
 Fatigue or loss of energy
 Feelings of worthlessness or inappropriate guilt
 Psychotic features may or may not be present

MAJOR DEPRESSIVE EPISODE
DSM-IV CRITERIA - CONTINUED




Other features:
A quality of depressed mood that is distinctly
different from the kind felt when a loved one is
lost or deceased
Depression is worse in the morning (Diurnal
Mood Variation)
Waking up 2 hours earlier than usual
DYSTHYMIA
DSM-IV CRITERIA

Depressed or irritable mood lasts at least one
year and is never symptom free for more than 2
months; in addition, two of the following must be
present:

Appetite change

Sleep change

Decreased energy
DYSTHYMIA
DSM-IV CRITERIA - CONTINUED

Low self-esteem

Difficulty making decisions or poor concentration

Feelings of hopelessness
ATYPICAL DEPRESSION
DSM-IV CRITERIA
Mood reactivity
 Increase in appetite or significant weight gain
 Increased sleep
 Feelings of heaviness in arms or legs
 A pattern of long-standing rejection sensitivity
that extends far beyond the mood disturbance
episodes and is significantly impairing

BIPOLAR DEPRESSION
Presents similarly to unipolar depression except
more likely to include the following:
 atypical depression (BORDERLINES)
 explosiveness with minimal or no external
provocation (BORDERLINES)
 pharmacologically induced hypomania
(hypomania induced by medications)
 family hx of bipolar disorder

SEASONAL AFFECTIVE DISORDER



Although there is minimal literature in
pediatrics, data suggests the possibility of SAD
in adolescent and prepubescent populations
living in climates with distinct seasonal change
Difficult to distinguish from school related cycles
Some literature support the benefits of
phototherapy
ADJUSTMENT DISORDER



Excessive change in mood and impairment of
functioning within 3 months of a significant
stressor
Self limited in duration
Less severe mood disturbance and fewer
symptoms than major depression
PREMENSTRUAL DYSPHORIC
DISORDER
In brief, mood symptoms which may include
 Anxiety
 Irritability
 depression,
 mood lability
 occurring in the last week of the luteal phase
and remitting within a few days of the
follicular stage.
 The disturbance significantly interferes with
school, work, relationships or social activities and
is not better accounted for by another disorder.

SYMPTOMS OF MAJOR DEPRESSIVE
DISORDER COMMON TO ADULTS,
CHILDREN, AND ADOLESCENTS
 Persistent
sad or irritable mood
 Loss of interest in activities once enjoyed
 Significant change in appetite or body
weight
 Difficulty sleeping or oversleeping
 Psychomotor agitation or retardation
SYMPTOMS OF MAJOR DEPRESSIVE
DISORDER COMMON TO ADULTS,
CHILDREN, AND ADOLESCENTS –
CONTINUED
 Loss
of energy
 Feelings of worthlessness or inappropriate
guilt
 Difficulty concentrating
 Recurrent thoughts of death or suicide
AGE RELATED SYMPTOM DIFFERENCES
 Depression
in children is more frequently
manifested by

Separation anxiety

Phobias


Somatic complaints (stomachaches,
headaches)
Behavioral problems.
AGE RELATED SYMPTOM
DIFFERENCES – CONTINUED
 Older
children and adolescents are more
likely to manifest
 Sadness
Psychosis
 Suicide attempts
 Acting out
 Substance abuse
 Increased lethality of suicide attempts
 Impaired functioning

SIGNS THAT MAY BE ASSOCIATED
WITH DEPRESSION IN CHILDREN
AND ADOLESCENTS
 Frequent
vague, non-specific physical
complaints such as headaches, muscle
aches, stomachaches or fatigue
 Frequent absences from school or poor
performance in school
 Talk of or efforts to run away from home
 Outbursts of shouting, complaining,
unexplained irritability, or crying
SIGNS THAT MAY BE ASSOCIATED
WITH DEPRESSION IN CHILDREN
AND ADOLESCENTS
– CONTINUED
 Being
bored
 Lack of interest in playing with friends
 Alcohol or substance abuse
 Social isolation, poor communication
 Fear of death
SIGNS THAT MAY BE ASSOCIATED
WITH DEPRESSION IN CHILDREN
AND ADOLESCENTS
– CONTINUED
 Extreme
sensitivity to rejection or failure
 Increased
 Reckless
irritability, anger, or hostility
behavior
 Difficulty
with relationships
CONDITIONS THAT MIMIC DEPRESSION
mononucleosis
 influenza
 encephalitis
 subacute bacterial
endocarditis

tuberculosis
 hepatitis
 CNS syphilis
 AIDS
 pneumonia

CONDITIONS THAT MIMIC DEPRESSION
– CONTINUED
seizure disorders
 postconcussion
 subarrachnoid
hemorrhage
 Cerebrovascular
accident
 multiple sclerosis
 Huntington’s disease

diabetes
 Cushing’sdisease
 Addison’s disease
 hypothyroidism
 hyperthyroidism
 hyperparathyroidism
 hypopituitarism

CONDITIONS THAT MIMIC
DEPRESSION
– CONTINUED
substance abuse and
withdrawal: alcohol,
cocaine,
amphetamines,
opiates
 hypokalemia
 hyponatremia
 failure to thrive
 anemia

uremia
 chronic fatigue
syndrome
 fibromyalgia
 porphyria
 Wilson’s disease
 lupus

DEPRESSION INDUCING MEDICATIONS
antihypertensives
 barbiturates
 corticosteroids
 oral contraceptives
 cimetidine
 aminophylline
 oral smoking
cessation medication
(Chantix)

anticonvulsants
 clonidine and
guanfacine
 digitalis
 thiazide diuretics
 psychostimulants
 oral anti-acne
medication
(Accutane)

EPIDEMIOLOGY
Major depression prevalence:
 2% childrenwith 1:1 female: male ratio,
 8% in adolescents with higher 2:1 to 4:1
female:male ratio
 cumulative incidence by age 18 is 20%
 Dysthymia prevalence:
 0.6 to 1.7% children;
 1.6 to 8 % in adolescents
 20 to 40% of adolescents with major depression
will develop Bipolar disorder within 5 years

ASIAN AMERICANS
Chinese, Filipino, Korean and Japanese
immigrants consistently report higher numbers
of depressive symptoms than Caucasians
 Asian Americans have the lowest utilization for
mental health services
 and are more likely to have psychotic diagnoses
in inpatient and outpatient settings.
 Studies further show that Asian Americans have
greater disturbance levels than do non-Asian
clients

ASIAN AMERICANS



71% of Southeast Asians meet the criteria for a
Major Affective Disorder (which includes
depression)
Hmong (85%) and Cambodians (81%) showing
the highest rates.
Moreover, 70% of Southeast Asian refugees are
found to have post-traumatic stress disorder
ASIAN AMERICAN TEENS



Among women aged 15 – 24:
Asian American adolescent girls have the highest
suicide mortality rates across all racial/ethnic
groups.
And the highest rates of depressive symptoms of
all racial/ethnic and gender groups.
ASIAN AMERICAN TEENS –
CONTINUED



Asian American college students report higher
levels of depressive symptoms than white
students.
Asian American adolescent boys are twice as
likely as whites to have been physically abused,
and three times as likely to report that they have
been sexual abused
SUSTAINED IRRITABILITY IN
CHILDREN: MAY BE AN INDICATOR
OF BIPOLARITY




Leibenluft, Charney, et al (two studies done
2003, 2006):
Irritability (a mood state characterised by anger
and easy annoyance)
which is continually present at a very young age
(often from the first year of life)
should be considered the typical mood of early
mania.
TIME SPENT IN SPECIFIC BIPOLAR
DISORDER AFFECTIVE SYMPTOMS
86 Bipolar Patients followed 13.4 years
Ratio of 39:1
Depressed vs. Hypomanic
% of Weeks
Asymptomatic 46%
Depressed 50%
Manic/Hypomanic 1%
Mixed 2%
Judd LL et al: Arch Gen Psych 2003, 60:261-269
TIME SPENT NOT GETTING PROPER
TREATMENT

The average time spent from the start of
symptoms to getting the proper diagnosis and
treatment is



10 YEARS (and this is just the average)
This means that, in the intervening years,
patients and their loved ones suffer and wallow
This is the Burden of the Illness
EPIDEMIOLOGY IN SPECIALIZED
PEDIATRIC POPULATIONS
 Depression:
 40%
of neurology inpatients for headache
 23%
of oncology inpatients
 59%
of psychiatric inpatients
 28%
of psychiatric outpatients
COMORBIDITIES



40 to 90% of those with Major depression will
have another psychiatric disorder
20 to 50% of those with Major depression will
have 2 or more psychiatric disorders
The most frequent comorbid disorders include:
 Anxiety - separation anxiety in children
 social phobia and generalized anxiety in
adolescents (30 to 80%)
COMORBIDITIES - CONTINUED
 dysthymia
“double depression” (30 to 80%)
 disruptive
behavior disorders (10 to 80%)
 substance
abuse (20 to 30%)

risk of suicide
DEPRESSION IS LIFE SHORTENING
 With
increased risk of
 Cardiovascular Events
 Stroke
 Metabolic Syndrome, including DM
 Heart Disease
 HPN
 others
RISK FACTORS
 Gender
– females > males
 Children
with at least one depressed
parent are 3 times more likely have a
Major depression with
 lifetime
 1st
risks range from 15 to 60%
degree relatives of a depressed child
have a 30 to 50% risk of depression
RISK FACTORS - CONTINUED
Twin studies found concordance for mood
disorders of
 Rates in monozygotes reared together
(identical) – 76%
 19% in dizygotes (fraternal)
 Rates in monozygotes reared apart - 67%
 Hx of previous psychiatric problems
 Educational challenges – learning disorders,
ADHD, school phobia
 Negative cognitive attributional styles

RISK FACTORS - CONTINUED


Early adverse events - parental separation or
death, impaired attachment
Exposure to negative life events: abuse, neglect,
trauma, disruption of relationships, chronic
medical problems

Dysfunctional family relationships

Neuroendocrine dysregulation?
BIOLOGICAL MARKERS
 Hypersecretion
of corticotropin-releasing
factor
 Dexamethasone nonsuppression of cortisol
 Hyposecretion of growth hormone in
response to insulin challenge and
hypersecretion during sleep
 Decreased levels of norepinephrine and
serotonin (risk for suicide) metabolites in
CSF
BIOLOGICAL MARKERS –
CONTINUED
 Various
sleep study results show
 decreased REM latency
 increased REM density
 decreased sleep efficiency
GRAY MATTER LOSS
THE NEED FOR NEUROPROTECTION
EFFECTS OF DEPRESSION ON THE
BRAIN: HIPPOCAMPUS
 Imaging:
Hippocampal size decreases in
patients with Depression and PTSD
 Depression: nerve cells/appendages
become depleted of serotonin and “shrink”,
thereby reducing their ability to
communicate with each other
 TREATMENT CAN IMPROVE (reverse)
THIS ABNORMALITY IN THE SIZE OF
THE HIPPOCAMPUS BY WAY OF
NEUROGENESIS (creation of new nerve
pathways)
REMISSION MAY PROTECT THE BRAIN
FROM LONG-TERM DEPRESSION
RELATED CHANGES



Frodi TS et al Arch. Gen Psychiatry 2008; 65
(10): 1156-1165
Prospective, Longitudinal Study : 38 participants
with MDD/Depression and 30 controls were
followed for 3 years.
Brain Morphometry was assessed by MRI
REMISSION MAY PROTECT THE BRAIN
FROM LONG-TERM DEPRESSION
RELATED CHANGES
RESULTS
Patients with MDD/Depression who went into
remission showed significantly less volume
reduction in brain areas
of direct relevance to the pathophysiology of
MDD (VM prefrontal cortex, hippocampus,
amygdala)
 Patients with MDD/Depression who did not
achieve remission showed more volume reduction
in brain areas
of direct relevance to the pathophysiology of
MDD

PATIENTS WITH DEPRESSION (MDD)
WHO DID NOT RESPOND TO
ANTIDEPRESSANTS HAD HIGHER
INFLAMMATORY CYTOKINE LEVELS
 2007:
O’Brien SM et al, (J. Psychiatr Res; 41:
326-331)
 24
Healthy Controls and 28 patients with
Depression (HAM D >20, after 6 weeks of
treatment with SSRI’s ) and 16 euthymic
patients (previously resistant to SSRI’s and
currently successfully treated with SNRI’s or
SSRI’s + the mood stabilizer Lithium
PATIENTS WITH DEPRESSION (MDD)
WHO DID NOT RESPOND TO
ANTIDEPRESSANTS HAD HIGHER
INFLAMMATORY CYTOKINE LEVELS –
RESULTS
 TNFα (pg/ml) – averages
12 pg/ml – Controls
 20 pg/ml – Depressed
 8 pg/ml – Euthymic


p=0.004
 IL6
(pg/ml) – averages
0.9 pg/ml – Controls
 1.2 pg/ml – Depressed
 0.8pg/ml – Euthymic


p=0.01
INFLAMMATORY CYTOKINE
ACTIVITY INCREASE
Inflammation gone wild means increased risk :
 Cardiovascular Events
 Stroke
 Metabolic Syndrome, including Diabetes Mellitus
 Heart Disease
 HPN
 Infection
 Tissue Trauma
 Neoplasm

PSYCHOLOGICAL MODELS FOR
DEPRESSION
 Psychoanalytic:
Real or imaginary loss of
a loved object with “anger turned
inwards”.
 Learned
helplessness: Behavior is
independent of, or lacks reinforcers, thus
one gives-up in trying to change condition.
PSYCHOLOGICAL MODELS CONTINUED
 Life
Stress: Inability to adjust to
changes/stressors leads to depression.
 Behavioral
Reinforcement: Inadequate or
insufficient positive reinforcers contribute
to depression.
PSYCHOLOGICAL MODELS CONTINUED
 Self
Control: Deficits in selfreinforcement, self-evaluation and selfmonitoring result in depression.

Misattribute success to external
factors and failure to personal
factors.
PSYCHOLOGICAL MODELS CONTINUED

Cognitive Distortion: The triad –
personal life and the world are terrible
(negative personal/world view)
 nothing can be done to change this
(helplessness)
 the future holds more of the same
(hopelessness).

CLINICAL COURSE



Episode Duration:
 Major depression 7 to 9 months
 dysthymia 3 to 4 years
Relapse rates:
 major depression are 20 to 60% in the first 1 to
2 years of remission
 70 % after 5 years of remission
First episode of major depression usually occurs 2
to 3 years after the onset of dysthymia
CLINICAL COURSE
Untreated, major depression and dysthymia
affect a child’s development of
 social, emotional, cognitive and
interpersonal skills and attachment
relationships.
 Treatment delay averages 10 years
 There are high risks of suicidal behaviors,
substance abuse, medical illness, early
pregnancy, exposure to negative life events and
impaired academic and vocational functioning.

BURDEN OF ILLNESS
Residential Status
58% not living independently
Marriage
Only 21% married
Spouse/Partner Burden
> 57% report change in
social life
Employment Problems
64% unemployed
Financial Burden
>50% report increase
worries and strain
1. Kupfer DJ et al. J Clin Psycthiatre 2002, 63: 123-125
2. Lam D et al, Bipolar Disorder 2005, 7: 431-440
3. Post R.M. J Clin Psychiatry 2005, 66 (suppl 5) 5-10
HISTORICAL NOTES - SUICIDE
 Suicide
is
 the third leading cause of death among
adolescents (following accidents and
homicide)
 sixth leading cause among children.
HISTORICAL NOTES - SUICIDE


More teens and young adults die from suicide than from
cancer, heart disease, AIDS, birth defects, stroke,
pneumonia and influenza, and chronic lung diseases
combined.
One survey of medical examiners indicated probable
under reporting of suicide by 100%.
EPIDEMIOLOGY - SUICIDE

Suicidal ideation prevalence - 20%

Suicidal ideation with plan prevalence-10 %

Suicide attempt prevalence - 8%

Preadolescent suicide attempts - 1%
EPIDEMIOLOGY - SUICIDE
Suicide Rates per 100,000 (1998)
 Age 5 to 14 years - 0.8
 15 to 24 years - 11.1







White males - 19.3
Black males - 15.0
Hispanic males - 13.4
White females - 3.5
Black females - 2.2
Hispanic females - 2.8
EPIDEMIOLOGY - SUICIDE
 Females
attempt suicide 4 times more often
than males.
 Males are 3 times more successful than
females.
 Ratio of attempts to completions is 50:1
SUICIDE METHODS
Firearms 59%
 Hanging 19%
 Gases 11%
 Substances 6%
 Other 5%

1.4:1 male:female
1.5:1 male:female
1:1.3 male:female
1:7 male:female
1:2.3 male:female
TIMES AND SETTINGS FOR SUICIDE
 Monday
 Afternoon
and evenings
 March, April, May
 70% occur at home
 22 % occur outdoors
SUICIDE RISK FACTORS: PSYCHOPATHOLOGY
Previous attempt increases risk by 100 times
 Major depression increases risk by 27 times
 Bipolar disorder increases risk by 9 times
 Substance abuse increases risk by 9 times
 Conduct disorder increases risk by 6 times

SUICIDE RISK FACTORS: PSYCHOPATHOLOGY


Substance abuse with comorbid mood disorder
increases risk by 17 times
Personality traits of impulsivity, aggression, low
frustration tolerance and loneliness markedly
increase risk.
SUICIDE RISK FACTORS: NEGATIVE PERSONAL HISTORY
 Early
life disruptions in nurturing and
parenting
 Physical and sexual abuse, neglect
 Parental psychopathology
 Family hx of suicide increases risk by 5 times
 Interpersonal and social skill deficits
 Chronic illness and hospitalizations
SUICIDE RISK FACTORS: STRESS
Any affect arousing stimuli that threatens the ability
to maintain self-esteem and cope effectively. (May be
anticipated stressors but pose unacceptable rejection,
humiliation or feared punishment)
 Homosexuality increases risk by 2 to 6 times
 Disruption in intimate relationships

SUICIDE RISK FACTORS: STRESS
Family or peer loss
 Achievement pressure
 Runaway attempts (37% risk of suicide)
 Birth of siblings
 Frequent family moves

SUICIDE RISK FACTORS: BREAKDOWN OF DEFENSES
 Cognitive
rigidity
 Irrationality
 Thought disturbances
 Loss of reality testing
 Acute changes including disorientation,
rage, anxiety attacks
SUICIDE RISK FACTORS: ISOLATION AND
ALIENATION
 Behavioral
withdrawal from usual
supportive relationships
 Rejection of help and noncompliance
with treatment
 Identification with fringe and
marginal groups identified by their
alienation from mainstream society.
SUICIDE RISK FACTORS: SELF DEPRECATORY IDEATION
 Statements
of unhappiness,
pessimism,and irritability
 Feelings of worthlessness,
hopelessness, uselessness and
stupidity
 Inability to derive pleasure or be
pleased by others
 Death related fantasies
SUICIDE RISK FACTORS: MEANS
Accessibility
Knowledgeability
Lethality
BIOPSYCHOSOCIAL EVALUATION
AND TREATMENT
Medical evaluation including CBC with Diff,
chem panel, thyroid panel and possibly ECG,
EEG, MRI or CT of the brain
 Psychologic/psychiatric evaluation
 Multidisciplinary Treatment Team: Primary
Care Physicians, Child Life, Social Work,
Nursing, School teacher, ARNP’s,
Recreation/Occupational/Physical Therapists,
Psychologists, Psychiatrists

BIOPSYCHOLOGIC
EVALUATION/TREATMENT


Rating Scales:
 Beck Depression Inventory (BDI)
 MMPI-Adolescent
 Mood Disorder Questionnaire (MDQ)
Interview:
 Parent and Teen together
 separately
BIOPSYCHOSOCIAL
EVALUATION/TREATMENT - CONTINUED
Psychologic Treatment
 Educational Intervention
 Psychopharmacologic treatment
 Out-of- home placement
 Acute psychiatric hospitalization
 Residential treatment

PSYCHOTHERAPIES
Play therapy (chess, board and court games,
controlled video games, )
-can provide nonverbal communication
-discharge stress through motor activity
-express and deal with emotions through
symbolic play
-opportunity for success
-therapist provides healthy model for
identification
 Music and Art therapies can provide for similar
kinds of expression and relief while additionally
yielding concrete products of patient’s efforts.

PSYCHOTHERAPIES - CONTINUED
 Behavioral
Therapy:
 Response contingent positive
reinforcement
 Focus on skills especially interpersonal
skills which can be reinforced.
 Frequently paired with cognitive
therapy
PSYCHOTHERAPIES - CONTINUED

Insight oriented:
 Starts with supportive, moves to empathy,
then collaboration/self observing
 Therapists gives interpretations of anxiety and
affect
 May go from current relationships to past
relationships (looking back to move forward)
 Transference interpretations may be made
PSYCHOTHERAPIES - CONTINUED
 Life
Stress:
-Focus is on
Resolving
• modifying or
• accepting the stressor.
•
PSYCHOTHERAPIES - CONTINUED
 Cognitive:
•
-Therapist aids in correcting
cognitive distortions
via persuasion
challenging cognitions
examining evidence
exploring alternative explanations,
assessing consequences
-Therapists must be creative, cognitively
flexible, and energetic.
PSYCHOTHERAPIES - CONTINUED
 Group:
 Many
of the aforementioned
therapies can occur in group settings

with proper planning and structure
and adequate number of therapists.
PSYCHOTHERAPIES - CONTINUED
 Family

Therapy
-dynamics of relationships may need to
change i.e.
increase affection

increase communication
-clarify roles and reduce role diffusion
-moderate rigid or chaotic rule structures
-therapist will need specific training
PHARMACOTHERAPY



Evidence for efficacy in childhood mood disorders is
less than evidence for adult disorders
 High rate of placebo response
 Open trials show efficacy
Antidepressants are used widely in children due to
significant morbidity of the disorder
 7% of total antidepressants prescribed in 2002
were for pediatric population
Suggested approaches are based on data from adult
studies, as well as anecdotal, clinical, and research
experience
PHARMACOTHERAPY
 SSRI’s






Escitalopram (Lexapro) 2.5-20mg/day
Citalopram (Celexa) 5-60mg/day
Sertraline (Zoloft) 12.5-200mg /day
Paroxetine (Paxil/Paxil CR) 5-60mg/day
Fluvoxamine (Luvox) 25-300mg/day,
divided
Fluoxetine (Prozac) 2.5-80mg/day
PHARMACOTHERAPY
 Buproprion
(Wellbutrin/SR/XL) 100-450
mg/day
 Contraindicated with seizures
 Venlafaxine (Effexor/XR) 37.5-225 mg/day
 Mirtazepine (Remeron) 7.5-45 mg/day
 Tricyclics (Nortriptylline, Desipramine,
Imipramine, Elavil, Anafranil) – monitor
QT interval, levels
 MAO Inhibitors – rarely used because of
dietary restrictions, drug interactions
 Benzodiazepines – short term for anxiety
PHARMACOTHERAPY -- CONTINUED
 When
Bipolar Depression is suspected,
always use a mood stabilizer even when
the patient is depressed.
 Properly
wean off antidepressant when
Mania or Hypomania emerges
 33%
of Bipolar patients are susceptible to
antidepressant-induced mania, mood
acceleration, mood destabilization.
ALGORITHM
Start with an SSRI.
 If needed, take to maximum as tolerated
 Change to another SSRI
 Try different class of antidepressant
 Augmentation






Another antidepressant
Lithium, Valproate, Lamotrigine, Tegretol (mood
stabilizers)
Atypical antipsychotics (can help stabilize mood)
Benzodiazepines
Thyroid augmentation
ALGORITHM – REMEMBER:
When Bipolar Depression is suspected, always
use a mood stabilizer even when the patient is
depressed.
 Properly wean off antidepressant when Mania or
Hypomania
 Or when depression worsens or suicidal ideation
emerge as antidepressants are being
administered.
 Because in 33% of Bipolar patients,
antidepressants c can induce mood
destabilization, mania, or mood acceleration.

LENGTH OF TREATMENT
First
Episode – 9-12 months
Two episodes – minimum two
years
Three episodes – five years to
life
PHARMACOTHERAPY ISSUES

Disinhibition, activation

Medication-induced mania

Cytochrome p450 inhibition

Paxil, Prozac (2D6)

Withdrawal symptoms

That FDA warning
PHARMACOTHERAPY ISSUES - CONTINUED



Aug 2003 – Effexor manufacturer sends letter to
MD’s saying it should not be used in depressed
pediatric patients due to “signal” of suicidality in
data
Oct 2003 – FDA advises close monitoring of all
patients on antidepressants
Dec 2003 – Britain adds pediatric
contraindications to Effexor, Zoloft, Celexa, and
Lexapro (only Prozac is approved, others are not
available)
WHAT IS FDA APPROVED?
 Fluoxetine
and Escitalopram (Lexapro)
are FDA approved for use in children and
adolescents with depression(7-17 yo) (and
OCD)
 Zoloft (6-17 yo) and Luvox (8-17 yo) are
FDA-approved for treatment of ObsessiveCompulsive Disorder in children and
adolescents
 Paxil/CR and Effexor/XR are currently not
recommended for use in children with
depression
WHAT SHOULD I, THE HEALTH CARE
PROVIDER, DO?

Explain the risks and advisory to parents
Monitor carefully for suicidal ideations, increased
agitation, or worsening of depression, especially
when starting and increasing or decreasing doses
 This includes patients of all ages.


Familiarize yourself with the use of second
generation antipsychotic medications or mood
stabilizers that can act as a “brake” to possible
antidepressant induce mood destabilization.
RECAP: IMPORTANT TAKE HOME
MESSAGES
Depression is treatable, but tends to be chronic
with 85% who experience a single episode
experiencing another episode within 15 years.
 For the sake of NEUROPROTECTION, do not
ignore symptoms
 Early onset, consider Bipolar Depression
 Use BDI and MDQ as screening tools
 Be mindful Family History
 Discern when it is better to add mood
stabilizers and/or second generation
antipsychotics vs. prescribing antidepressants

alone
REFERRAL

Psychiatric referrals may be helpful when





diagnoses are in question
interventions are not successful
transference/counter transference
issues may be interfering with
treatment
systems issues occur in which a
“consultant” may be helpful
when life threatening signs and
symptoms are detected i.e. suicidality,
psychosis, substance use.
THE SCOPE OF MENTAL HEALTH
DISORDERS
One in five Americans experience some form of
mental disorder each year
 One in five children experiences symptoms of a
diagnosable mental disorder each year
 Mental illness accounts for 15% of the total years
of productive life lost to disability or premature
death
 90% of depressive disorders respond to tx

INDEX
Cytochrome 2D6 substrates, inducers and
inhibitors:
http://www.ildcare.nl/Downloads/artseninfo/Drug
s_metabolized_by_CYP450s.pdf
o Mood Disorder Questionnaire:
http://www.dbsalliance.org/pdfs/MDQ.pdf
o Beck Depression Inventory Scoring:
http://www.drcordas.com/education/mooddisorders/
Scoring%20the%20Beck%20Depress.pdf
