Mood DisordersMood DisordersOctober 9, 2007October 9, 2007

Mood DisordersMood Disorders

Any disturbance in moodAny disturbance in mood Extreme, persistent, or poorly Extreme, persistent, or poorly

regulated emotional statesregulated emotional states Major Depressive DisorderMajor Depressive Disorder Dysthymic DisorderDysthymic Disorder Bipolar DisorderBipolar Disorder

Major Depressive Major Depressive DisorderDisorder

Prior to 1970’sPrior to 1970’s

Before 1970's childhood depression Before 1970's childhood depression was rarely discussedwas rarely discussed

Children and depression?Children and depression? WHY?WHY?

Depression in ChildrenDepression in Children

One of the most disabling childhood One of the most disabling childhood disordersdisorders

Prevalence is increasing and age of Prevalence is increasing and age of onset is decreasingonset is decreasing

Experience and expression changes Experience and expression changes with agewith age

Under age 7 tends Under age 7 tends diffuse and less diffuse and less easily identifiedeasily identified

Developmental CourseDevelopmental Course

Age of onset usually between 13-15 Age of onset usually between 13-15 yearsyears

Average episode = 8 monthsAverage episode = 8 months Often continue to experience Often continue to experience

adjustment and health problems and adjustment and health problems and chronic stresschronic stress

Gender differences:Gender differences: Pre-puberty: 50/50 Pre-puberty: 50/50 Post-puberty: Girls 2-3x more likelyPost-puberty: Girls 2-3x more likely

Developmental Course Developmental Course of MDDof MDD

Figure 8.1Figure 8.1 Adapted from “Development of Depression from Adapted from “Development of Depression from Preadolescence to Young Adulthood: Emerging Gender Differences Preadolescence to Young Adulthood: Emerging Gender Differences in a 10-year-Longitudinal Study,” by B. L. Hankin, L. Y. Abramson, in a 10-year-Longitudinal Study,” by B. L. Hankin, L. Y. Abramson, T. E. Moffitt, P. A. Silva, R. McGee & K. E. Andell, 1998, Journal of T. E. Moffitt, P. A. Silva, R. McGee & K. E. Andell, 1998, Journal of Abnormal Psychology, 107, 128-140. Copyright (c) 1998 by the Abnormal Psychology, 107, 128-140. Copyright (c) 1998 by the American Psychological Association. Reprinted by permission of American Psychological Association. Reprinted by permission of the author.the author.

DSM-IV Criteria ADSM-IV Criteria A

depressed mood/sadness most of the day, depressed mood/sadness most of the day, most daysmost days

diminished interest or pleasure in activitiesdiminished interest or pleasure in activities changes in appetite or weightchanges in appetite or weight sleep disturbancessleep disturbances psychomotor retardation or agitationpsychomotor retardation or agitation fatigue or loss of energyfatigue or loss of energy feelings of worthlessness or inappropriate feelings of worthlessness or inappropriate

guiltguilt difficulty thinking or concentratingdifficulty thinking or concentrating thoughts of death or suicidal ideationthoughts of death or suicidal ideation

Criteria B-DCriteria B-D

B. The symptoms do not meet criteria for B. The symptoms do not meet criteria for a Mixed Episode (Mania + Depression)a Mixed Episode (Mania + Depression)

C. The symptoms cause C. The symptoms cause significant significant distressdistress or or impairmentimpairment in social, in social, occupational, or other important areas occupational, or other important areas of functioningof functioning

D. Symptoms are not due to the direct D. Symptoms are not due to the direct effects of a substance (e.g., a drug of effects of a substance (e.g., a drug of abuse, a medication) or a general abuse, a medication) or a general medical condition (e.g., medical condition (e.g., hypothyroidism).hypothyroidism).

Criteria ECriteria E

E. Symptoms are not accounted for by E. Symptoms are not accounted for by BereavementBereavement; or the bereavement ; or the bereavement symptoms persist for longer than 2 symptoms persist for longer than 2 months or are characterized by months or are characterized by marked functional impairment, marked functional impairment, morbid preoccupation with morbid preoccupation with worthlessness, suicidal ideation, worthlessness, suicidal ideation, psychotic symptoms, or psychomotor psychotic symptoms, or psychomotor retardationretardation

DSM-IV Criteria ADSM-IV Criteria A

depressed mood/sadness most of the day, depressed mood/sadness most of the day, most daysmost days

diminished interest or pleasure in activitiesdiminished interest or pleasure in activities changes in appetite or weightchanges in appetite or weight sleep disturbancessleep disturbances psychomotor retardation or agitationpsychomotor retardation or agitation fatigue or loss of energyfatigue or loss of energy feelings of worthlessness or inappropriate feelings of worthlessness or inappropriate

guiltguilt difficulty thinking or concentratingdifficulty thinking or concentrating thoughts of death or suicidal ideationthoughts of death or suicidal ideation

Prevalence & Prevalence & ComorbidityComorbidity

Prevalence:Prevalence: 2-8% of children ages 4-182-8% of children ages 4-18 more rare among preschool and school-age more rare among preschool and school-age

children, increases into adolescence and children, increases into adolescence and adulthoodadulthood

Most common comorbid disorders are:Most common comorbid disorders are: anxiety disordersanxiety disorders dysthymiadysthymia conduct problemsconduct problems ADHDADHD substance use disordersubstance use disorder

Dysthymic Dysthymic DisorderDisorder

Dysthymic DisorderDysthymic Disorder

Features:Features: less severe than MDDless severe than MDD less anhedonia, social withdrawal, less anhedonia, social withdrawal,

impaired concentration, death thoughts, impaired concentration, death thoughts, and physical complaintsand physical complaints

more constant sadness, self-more constant sadness, self-depreciation, low self-esteem, anxiety, depreciation, low self-esteem, anxiety, irritability, anger, and temper tantrumsirritability, anger, and temper tantrums

““Double depression”Double depression”

Prevalence & Prevalence & ComorbidityComorbidity

1% of children and 5% of 1% of children and 5% of adolescentsadolescents

Most common comorbid disorder is Most common comorbid disorder is MDDMDD

AssessmentAssessment

AssessmentAssessment

Multiple methods of assessment are Multiple methods of assessment are criticalcritical

Older children better self-reportersOlder children better self-reporters Self-report unhelpful before age 8Self-report unhelpful before age 8

Parents may or may not have insightParents may or may not have insight Obtain parent ratings of general child Obtain parent ratings of general child

functioningfunctioning CBCL, BASCCBCL, BASC

InterviewInterview

InterviewsInterviews Parents, child interviewed separatelyParents, child interviewed separately

With child, coverWith child, cover General and specific self-reportsGeneral and specific self-reports Discussion of mood and daily activitiesDiscussion of mood and daily activities Suicidal ideation, behaviorSuicidal ideation, behavior

Challenges in Challenges in AssessmentAssessment

Younger children cannot describe Younger children cannot describe their emotional experiencestheir emotional experiences

Caregivers limited reports of younger Caregivers limited reports of younger children’s internal stateschildren’s internal states

May reflect problems of parent rather May reflect problems of parent rather than childthan child

Lack of agreement between children, Lack of agreement between children, parents, and teachers on symptomsparents, and teachers on symptoms

Depression in Depression in AdolescentsAdolescents

Depression in late adolescence may Depression in late adolescence may have some developmental have some developmental distinctivenessdistinctiveness

Common symptoms in adolescents Common symptoms in adolescents include:include: anhedonia (lack of pleasure)anhedonia (lack of pleasure) psychomotor retardation (slowing psychomotor retardation (slowing

down)down)

Children’s Depression Children’s Depression Inventory (CDI)Inventory (CDI)

Purpose:Purpose: It’s a 27 item self-report It’s a 27 item self-report measures depression in children and measures depression in children and

adolescentsadolescents Administration:Administration:

8-17 years8-17 years 10-15 minutes to complete10-15 minutes to complete

Reynolds Adolescent Reynolds Adolescent Depression Scale (RADS)Depression Scale (RADS)

Purpose:Purpose: It’s a 30 item self-report measure It’s a 30 item self-report measure

designed to assess depressive affective designed to assess depressive affective symptomatology in adolescents ages 13-symptomatology in adolescents ages 13-18 18

It assesses clinically relevant levels of It assesses clinically relevant levels of depressive symptomatology in depressive symptomatology in individual adolescentsindividual adolescents

SuicideSuicide

33rdrd leading cause of deaths in leading cause of deaths in adolescentsadolescents

Suicide has quadrupled in Suicide has quadrupled in adolescence in the last 50 yearsadolescence in the last 50 years

National Youth Risk Behavior Survey:National Youth Risk Behavior Survey: 24.1% - seriously considered attempting 24.1% - seriously considered attempting

suicidesuicide 17.7% - had a specific plan17.7% - had a specific plan 8.7% - made an attempt8.7% - made an attempt

Suicide Risk FactorsSuicide Risk Factors

GenderGender History of History of

depressiondepression Previous suicide Previous suicide

attemptattempt Family hx of mental Family hx of mental

illnessillness Hx of sexual/physical Hx of sexual/physical

abuseabuse Social isolationSocial isolation

Family disruptionFamily disruption Chronic or Chronic or

debilitating illnessdebilitating illness Alcohol useAlcohol use Living out of the homeLiving out of the home Psychosocial Psychosocial

problemsproblems Easy access to lethal Easy access to lethal

methodsmethods SexualitySexuality

Suicide ResourcesSuicide Resources

Alachua County Crisis CenterAlachua County Crisis Center 24-hour telephone crisis intervention 24-hour telephone crisis intervention

and counseling service and counseling service Mobile outreach teamMobile outreach team Survivors of Suicide support groupSurvivors of Suicide support group http://http://crisiscenter.alachua.fl.uscrisiscenter.alachua.fl.us// 1(352) 264-6789 1(352) 264-6789

National Suicide HotlineNational Suicide Hotline 1(800) SUICIDE1(800) SUICIDE

Baker ActBaker Act

Florida Statute 394.467 Florida Statute 394.467 He or she has refused voluntary

placement for treatment after sufficient and conscientious explanation and disclosure of the purpose of placement for treatment; or

He or she is unable to determine for himself or herself whether placement is necessary; and

Baker ActBaker Act

Florida Statute 394.467 Florida Statute 394.467 He or she is manifestly incapable of

surviving alone or with the help of willing and responsible family or friends, including available alternative services, and, without treatment, is likely to suffer from neglect or refuse to care for himself or herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; or

Baker ActBaker Act

There is substantial likelihood that in the near future he or she will inflict serious bodily harm on himself or herself or another person, as evidenced by recent behavior

Bipolar DisorderBipolar Disorder

Bipolar Disorder (BD)Bipolar Disorder (BD)

FeaturesFeatures periods of periods of abnormally and persistently elevatedabnormally and persistently elevated, ,

expansive, or irritable expansive, or irritable moodmood, , alternating withalternating with one or more major one or more major depressive episodesdepressive episodes

may display symptoms such as over-excitement, may display symptoms such as over-excitement, restlessness, agitation, sleeplessness, pressured restlessness, agitation, sleeplessness, pressured speech, flight of ideas, sexual disinhibition, speech, flight of ideas, sexual disinhibition, inflated self-esteem, reckless behaviorinflated self-esteem, reckless behavior

several DSM subtypes, based on whether several DSM subtypes, based on whether youngster displays a manic, mixed, or youngster displays a manic, mixed, or hypomanic episodehypomanic episode

Prevalence and Prevalence and Comorbidity of BPComorbidity of BP

Lifetime estimates of 0.4%-1.2%Lifetime estimates of 0.4%-1.2% Extremely rare in young children, Extremely rare in young children,

but increases after puberty (when but increases after puberty (when rates are as high as for adults)rates are as high as for adults)

Affects males and females equallyAffects males and females equally Most commonly comorbid with Most commonly comorbid with

anxiety disorders, ADHD, conduct anxiety disorders, ADHD, conduct disorders, and substance abusedisorders, and substance abuse

Developmental Course of Developmental Course of BPBP

Peak age of onset between 15 - 19 Peak age of onset between 15 - 19 years of ageyears of age

Depression usually appears firstDepression usually appears first Chronic and resistant to treatment, Chronic and resistant to treatment,

with poor long-term prognosiswith poor long-term prognosis

Causes of BPCauses of BP

In adults suggests: the result of a In adults suggests: the result of a genetic vulnerability in combination genetic vulnerability in combination with environmental factors (e.g., life with environmental factors (e.g., life stress, family disturbances)stress, family disturbances)

Understudied in children!!!Understudied in children!!!

Treatment of BPTreatment of BP

Treatment must be multi-modal and Treatment must be multi-modal and often includes:often includes: education of the patient and the family education of the patient and the family

about the illnessabout the illness medication, usually lithiummedication, usually lithium psychotherapeutic interventions to psychotherapeutic interventions to

address symptoms and related address symptoms and related psychosocial impairmentspsychosocial impairments

Treatment for Treatment for DepressionDepression

MedicationsMedications tricyclic antidepressant medications tricyclic antidepressant medications Fluoxetine (Prozac) Fluoxetine (Prozac)

Antidepressants and suicide risk?Antidepressants and suicide risk?

PreventionPrevention CBT is most effective at lowering risk CBT is most effective at lowering risk

for depression, as well as preventing for depression, as well as preventing recurrencesrecurrences

Treatment for Treatment for DepressionDepression

Psychosocial InterventionsPsychosocial Interventions Cognitive-behavioral therapy (CBT)Cognitive-behavioral therapy (CBT) Interpersonal therapyInterpersonal therapy