Mad or Sad: Identifying

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Mad or Sad? Identifying Treating Mood
Disorders in Children Adolescents

• Eva Szigethy, MD, PhD
• Childrens Hospital Boston
• Harvard Medical School
• November 1, 2003

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The Many Faces of Depression

• Depressed, Irritable or Angry Mood
• School, Social or Behavior Problems
• Substance Abuse
• Family Difficulties
• Elation, Mania
• Somatic Complaints

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DSM-IV Criteria for Adult Major Depression

• Persistent depressed/irritable mood
• Change in sleep
• Change in appetite/weight
• Fatigue
• Decreased concentration
• Psychomotor change

• Anhedonia
• Worthlessness
• Thoughts of death/suicidality
• Guilt
• Hopelessness

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Depression in Pre-Schoolers

• Intense separation anxiety/neediness
• Attention seeking
• Dysphoria, irritability, crying spells
• Somatic complaints
• Regressive behavior
• Sleep/appetite disturbance
• Apathy in play or exploration
• Spending much time crying/rocking

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Depression in School Age Children

• Somatic complaints common
• Poor school performance
• Irritability, social withdrawal, inability to
  cope with minor frustrations
• Complaints of feeling bored, loss of interest
• Temper tantrums
• Boys- negativism, aggression, conduct problems
• Girls- behavioral inhibition, withdrawal

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Atypical Depression in Adolescents

• Mood reactivity- mood brightens with positive
  events
• Dysphoria without stating their feelings or
  volatile mood
• Report feeling stupid, down, bored
• Change in motivation/social withdrawal
• Increased appetite/increased sleep
• Decreased performance in school, chores, sports
• Intense self-consciousness/body concerns/low self
  esteem
• Rejection sensitivity
• Excessive fatigue/Leaden Arms/Legs

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Prevalence of Depression in Children and
Adolescents

• Prevalence in general population
• 0.3-0.9 preschoolers (MF)
• 1-2 school age (MF)
• 4-8 adolescents (FM)
• 2-12 adult (M) 5-26 adult (F)
• Prevalence in pediatric medical population
• 2-3x higher than general population

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Adolescent Depression

• Increase rates of depression post-puberty with
  change in sex ratio
• 20-25 of adolescents have at least one
  depressive episode by age 18
• 40-70 of depressed youth have a co-morbid
  psychiatric disorder

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Suicidality

• 8 of high school students make serious attempts
  each year (CDC, 1997)
• 13/100,000 completed suicides each year in
  adolescents
• Risk factors
• Depression
• Substance abuse
• Poor social adjustment/recent arguments
• Loss of parent
• Family Discord

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Risk Factors for the Onset of Depression

• Parent with mood disorder- both genetics and
  environment
• Severe stressors (loss, parental conflict,
  trauma, school failure, peer rejection, or
  physical illness)
• Low self-esteem, low self-efficacy, hopelessness,
  helplessness
• Being female
• Being in a disadvantaged position (economic,
  ethnic, social)

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When to Refer

• When sadness/depression/anger compromises
  functioning
• Major shifts in friends, school, family
• Parents/patient feels overwhelmed
• Any question of self-harm

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Biopsychosocial Treatment Plan
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Depression Pharmacotherapy Indications

• Sufficiently severe to interfere with functioning
• Severe depression neurovegetative or suicidal
• History of recurrent depression that does not
  respond to psychotherapy
• Psychotic or bipolar depression
• Positive antidepressant response for depression
  in first degree relatives
• Comorbid psychiatric disorders

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What Med to Choose?

• Consider side effect profile
• Consider drug interactions
• Consider compliance
• Consider safety
• Consider co-morbid conditions
• Consider family history

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Antidepressant Treatment

• Tricyclic Antidepressants (NE SE)
• Serotonin Selective Reuptake Inhibitors (SE)
• Atypical Antidepressants
• Wellbutrin (DA NE)
• Effexor (NE SE)
• Serzone (5HT-2 antagonist)
• Remeron (5HT2,3 antagonist)

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SSRIs- Common Side Effects

• CNS stimulation
• Insomnia, anxiety, agitation, nervousness
• Manic activation
• Sexual side effects decreased libido
  anorgasmia
• Gastrointestinal symptoms, nausea
• Tremor
• Weight loss/gain

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Atypical Antidepressants

• Buproprion- seizures, appetite decrease,
  agitation, tics
• Venlafaxine- sedation, nausea, HTN
• Nefazadone- liver toxicity, sedation, dry mouth
• Mirtazapine weight gain, sedation
• Trazadone- sedation, priapism

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Major Depression Treatment Algorithm Texas
Project

• Non-medication options
• SSRI
• Alternative SSRI partial augment (Li, Buspar)
• Alternative Class
• Combination (TCA SSRI, BUP SSRI)
• MAO Inhibitors
• ECT (Hughes et al, JAACAP, 381999)

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Beginning Antidepressants in Children

• Use trial of psychotherapy first and continue
  during med trial to address environmental,
  psychological and social problems associated with
  depression
• Inform parents about risks, dose, time course of
  benefits, risks of overdose, and drug-drug
  interactions
• Start low dose and go slow
• If first episode, good recovery, minimal family
  history, continue 9-12 months after response
• If severe, prolonged first episode, major family
  history, few side effect, continue 1-3 years

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BUTDownside to Antidepressants in Youth

• Long-term developmental impact and effectiveness
  of SSRIs is not determined in this population.
• Rates of SSRI-induced manic episodes may be as
  high as 20.
• Often antidepressants do not work in youth-
  possibly due to developing chemical systems in
  brain
• Recent studies implicating paroxetine (Paxil) and
  venlafaxine (Effexor) in increased suicidal
  thoughts and agitation in adolescents, though
  causality not proven.

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Therapy Modalities

• Psychodynamic Therapy
• Translate unconscious motives for behaviors into
  words in the context of a human relationship
• Cognitive Behavioral Therapy (CBT)
• Problem oriented treatment that seeks to identify
  and change maladaptive beliefs and behaviors
• Interpersonal Therapy (IPT)
• Grief, interpersonal disputes, role transitions,
  interpersonal deficits
• Family Therapy

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Psychotherapy vs. Antidepressant Medication

• Psychotherapy
• CBT effective for treatment of uncomplicated
  depression
• CBT has been shown to be effective in the
  longer-term prevention of relapse in major
  depression.
• Antidepressants
• May be more useful for more severe depression.
• More rapid onset of action than psychosocial
  interventions.
• Can be useful if co-morbid anxiety disorder or
  eating disorder is present

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Change in CDI Score Over Time Post CBT
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Assumptions of Cognitive Behavioral Therapy

• Emotions, thoughts and behaviors are connected
  and interact with environment
• Based on adult models proposing skill deficits or
  deviant cognitive structure in adult repertoires
• Adolescent social skills and repertoires less
  stable
• Adolescents more influenced by environment
  (modeling, prompting, rewarding, punishing)
• Under stress, maladaptive processing systems are
  activated/primed

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What is CBT?

• Identifying mood/mood monitoring
• Pleasant activity scheduling
• Behavioral problem solving
• Relaxation/guided imagery
• Target negative cognitive distortions
• Communication skills/conflict resolution
• Social skills training
• Humor to cognitively reframe
• Develop long-term goals

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Weiszs Skills and Thoughts Model

• Gain control over mood by developing skills to
  cultivate primary and secondary control
• Primary control changing objective conditions
  to make them fit wishes
• Secondary control changing expectations to
  adjust to objective conditions and thus control
  their subjective impact

• Skill deficits and cognitive habits may generate
  sad affect in response to adverse stressful or
  ambiguous life events
• Skill deficits poor activity selection, poor
  self-soothing, un-engaging social style
• Cognitive Habits negative cognitions,
  rumination, perceived helplessness hopelessness,
  lack of control

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ACT THINK Chart

• A Activities
• C Calm Confident
• T Talents

• T Think Positive
• H Help from a
• Friend
• I Identify the Silver
• Lining
• N No Replaying
• Bad Thoughts
• K Keep Trying-
• Dont Give Up

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Outline of CBT Sessions

• Session 1 Introduce PASCET, learn problem
  solving approach
• Session 2 Choosing activities that you enjoy
• Session 3 Activities with others, improving
  interpersonal skills
• Session 4 Relaxation techniques including guided
  imagery
• Session 5 Showing positive self- improving
  social skills
• Session 6 Developing talents and skills
• Session 7 Addressing negative cognitive
  distortions
• Session 8 Addressing negative cognitive
  distortions about physical illness
• Session 9 Positive reframing and practicing
  social skills
• Session 10-12 Review of skills learned and
  personalizing skills.

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Case Presentation

• 14 y.o. white female
• New onset x 3 months of feeling sad, easily
  frustrated, decreased motivation and energy, I
  hate myself, and stomach aches
• Downward shift of grades, isolated from friends,
  and decreased after-school activities

• Has inflammatory bowel disease with abdominal
  pain
• Coping with parental tension
• Mother with depression, father often critical

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Working Hypotheses

• Skills and Thoughts Model
• C has a number of skill deficits including social
  withdrawal, poor self-soothing abilities in the
  face of perceived rejection from peers, poor
  selection of reinforcing activities, decline in
  academic skills.
• C has a number of maladaptive cognitive habits
  such as lack of perceived control over her
  environment, negative cognitive distortions, and
  distorted self image.
• Together these negative behaviors and thoughts
  make her more vulnerable to feeling depressed.

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CBT skills most likely to help

• Teach coping skills to elicit PRIMARY control
• Scheduling fun activities alone and with others
• Relaxation to help counter pain
• Showing more positive self in social situations
• Teach ways to change thinking in situations that
  cant be changed to elicit SECONDARY control
• Thinking less negatively by identifying cognitive
  distortions and replacing with more positive
  thoughts
• Mood monitoring to link emotions, thoughts and
  behaviors.

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Four Promising Approaches to Treat Depression

• Cognitive behavioral preventions for those with
  major risk signs- Clarke
• Classroom and school-based preventions for those
  already showing some symptoms-Seligman
• Public health family-based prevention approaches-
  Beardslee
• Identifying, treating, and preventing depression
  in adolescents with physical illness- Szigethy

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The Preventive Intervention Research Cycle
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Oh, the Places Youll Go! By Dr. Seuss

• Congratulations! Today is your day. Youre off
  to Great Places! Youre off and away!
• You have brains in your head. You have feet in
  your shoes. You can steer yourself any direction
  you choose.
• Out there things can happen and frequently do to
  people as brainy and footsy as you. And when
  things start to happen, dont worry, Dont stew.
  Just go right along, Youll start happening too.
• And will you succeed? Yes! You will, indeed!
• Oh! The places youll go!