Diagnosis and Treatment of Depressive Disorders in Children and Adolescents Joel V. Oberstar, M.D. CEO & Chief Medical Officer Adjunct Assistant Professor of Psychiatry University of Minnesota Medical School Disclosures Some medications discussed are not approved by the FDA for use in the population described. Some medications are not approved by the FDA for use in the manner discussed/described. Financial Conflicts PrairieCare Medical Group (co-owner) PrairieCare (CEO & Chief Medical Officer) CATCH, LLC (co-owner) Disclaimer Prevalence of Certain Pediatric Mental Illnesses The contents of his handout are for informational purposes only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical or psychiatric condition. Never disregard professional/medical advice or delay in seeking it because of something you have read in this handout. Material in this handout may be copyrighted by the author or by third parties; reasonable efforts have been made to give attribution where appropriate. Anxiety Disorders 13.0% Disruptive Disorders 10.3 Mood Disorders 6.2 Substance Use Disorders 2.0 Any Disorder 20.9 Shaffer, D., et al. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): Description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. JAACAP. 1996;35, 865 877. Prevalence of Certain Pediatric Major Depressive Disorder Types of Major Depressive Disorder Total: ~53 million U.S. children ages 5-17 ~5%-10% have subsyndromal MDD = ~4 million ~2%-8% have MDD = ~2.1 million ~60% have suicidal ideation = ~1.2 million ~30% make a suicide attempt = ~630,000 US Census Bureau. http://www.census.gov/popest/national/asrh/nc-est2007/nc-est2007-02.xls. Accessed November 23, 2008. Birmaher B, Brent D, and the AACAP Work Group on Quality Issues, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007 Nov;46(11):1503-26. Major Depressive Disorder Persistent Depressive Disorder Adjustment Disorder Bereavement Bipolar Disorder Substance-Induced Depressive Disorder Non-Psychiatric Causes Joel V. Oberstar, M.D. 1
Assessment of Pediatric Major Depressive Episode Physical/Medical Differential Diagnosis hypothyroidism mononucleosis, anemia, certain cancers, autoimmune diseases, premenstrual dysphoric disorder, chronic fatigue syndrome stimulants, corticosteroids, contraceptives Depressed mood or loss of interest/pleasure in life activities + 4 of: Weight change Sleep disturbance Psychomotor change Fatigue/low energy Worthlessness/guilt Poor concentration Thoughts of death/dying/suicide 2+ weeks Children and Adolescents with. JAACAP. 2007;46(11):1503-1526. Adapted from: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). American Psychiatric Association. 2000. http://www.behavenet.com/capsules/disorders/mjrdepep.htm. Persistent Depressive Disorder Adjustment Disorder w/depressed Mood Depressed/Irritable mood most of the day, more days than not, for 2+ years (1+ in kids) 2+ of the following Appetite change Sleep change Low energy or fatigue Low self esteem Concentration problems Feeling hopeless Not more than a 2-month period free of symptoms Not another illness Depressed mood occurring within 3 months of a stressor Clinically significant (distressing/impairing) Resolves 6 months after the stressor is gone Not another Axis I disorder Adapted from: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). American Psychiatric Association. 2000. http://www.behavenet.com/capsules/disorders/dysd.htm. Adapted from: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). American Psychiatric Association. 2000. http://www.behavenet.com/capsules/disorders/adjdis.htm. Bereavement Substance-Induced Depressive Disorder Grief related to a loss Usually time-limited and not severe or significantly impairing Depressed mood or decreased interest/loss of pleasure in most activities Begins during or within one month of substance intoxication/withdrawal Substances with potential to cause depression -Cannabis -Alcohol -Cocaine -Ecstasy Adapted from: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). American Psychiatric Association. 2000. http://www.behavenet.com/capsules/disorders/s-imooddis.htm. Joel V. Oberstar, M.D. 2
Major Depressive Disorder (MDD) in Children and Adolescents Epidemiology of Pediatric Epidemiology and impact of illness Symptoms of MDD Developmental impact of MDD Treatment arsenal Psychotherapy Pharmacotherapy Role of psychoeducation MDD Prevalence ~2% in children; ~4-8% in adolescents MDD Female:Male ratio 1:1 in children; 2:1 adolescence Dysthymic Disorder 0.6% to 1.7% in children 1.6% to 8.0% in adolescents Children and Adolescents with. JAACAP. 2007;46(11):1503-1526. Differences in Clinical Presentation Differences in Clinical Presentation Children: Anxiety and somatic complaints Irritability/frustration manifested as temper tantrums Less able to verbalize feelings Less frequently make serious suicide attempts Adolescents: Sleep and appetite disturbances Suicidal ideation and suicide attempts More functionally impaired than children More behavioral problems than adults Fewer neurovegetative symptoms than adults. JAACAP. 1998;37(10 Supplement):63S-83S.. JAACAP. 1998;37(10 Supplement):63S-83S. Developmental Impact of MDD 10 Leading Causes of Death MN 1999-2005; ages 1-18 yoa Untreated MDD can result in: Impairment in the attachment bond between parent and child Impairment in the child s development of social, emotional, cognitive, and interpersonal skills High risk of suicidality, substance abuse, physical illness, early pregnancy Poor work, academic, and psychosocial functioning Relapses of MDD can derail the process of improving psychosocial functioning 1. Unintentional Injury 1055 2. Suicide 232 3. Malignant Neoplasms 221 4. Homicide 126 5. Congenital Anomalies 124 6. Heart Disease 62 7. Chronic Resp Disease 26 8. Influenza/Pneumonia 21 9. Anemias 16 10. Benign Neoplasms - 16 Depressive Disorders. JAACAP. 1998;37(10 Supplement):63S-83S. WISQARS TM. Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System. Joel V. Oberstar, M.D. 3
Treatment of Three Phases of Treatment Acute: seeking response/remission Beck Depression Inventory 9 Children's Depression Rating Scale 28 Continuation: consolidate gains; avoid relapse Maintenance: longer term treatment for selected patients WISQARS TM. Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System. Children and Adolescents with. JAACAP. 2007;46(11):1503-1526. Acute Phase Treatment: Psychotherapy CBT Resolve the patient s distorted views of themselves, the world, and their future Amongst the most studied in kids Psychodynamic Help youth understand themselves, identify feelings, interact more effectively with others IPT Focus on grief, interpersonal roles, disputes, role transitions Behavior therapy, supportive and group psychotherapies also useful Acute Phase Treatment: Family Therapy Addressing family dynamics that contribute to the child s depression Gives parents skills to manage the child s irritability, defiance, and isolation Gives the clinician an opportunity to assess the parents mental health and to suggest treatment if appropriate. JAACAP. 1998;37(10 Supplement):63S-83S. Depressive Disorders. JAACAP. 1998;37(10 Supplement):63S-83S. Role of Psychoeducation Important for patient and family; education enhances treatment adherence Education re: MDD as an illness helps: parental self-blame blaming the patient the parent s identification of their own symptoms Education of teachers can enhance identification of MDD in kids. JAACAP. 1998;37(10 Supplement):63S-83S. Pharmacological Treatment of in the Acute Phase Studies: high placebo response If using a med SSRIs Possibly bupropion (particularly if comorbid ADHD) SNRIs second line TCAs not supported Assess @ 4 week intervals; titrate to remission If no improvement by week 8, consider alt agent Children and Adolescents with. JAACAP. 2007;46(11):1503-1526. Joel V. Oberstar, M.D. 4
Antidepressants Antidepressants Method of Action: Modify neurotransmitter levels One mechanism: reuptake inhibition Block action of cell structures that recapture neurotransmitters after they are initially released Key Neurotransmitters: Serotonin (5-HT) Norepinephrine (NE) Dopamine (D) SSRI selective serotonin reuptake inhibitors SNRI serotonin norepinephrine reuptake inhibitors Others bupropion, mirtazapine, trazodone TCA tricyclic antidepressants MAOI monoamine oxidase inhibitors Antidepressants: SSRI s fluoxetine (Prozac, Prozac Weekly ) sertraline (Zoloft ) paroxetine (Paxil, Paxil CR ) citalopram (Celexa ) & escitalopram (Lexapro ) All serotonin levels S/E: sexual side effects, sleep disturbance, weight gain, suicidality Common SSRI Side Effects Gastrointestinal symptoms Sleep changes (e.g., insomnia/somnolence, vivid dreams, nightmares, impaired sleep) Restlessness or akathisia Diaphoresis Headaches Changes in appetite (increase or decrease) Sexual dysfunction Children and Adolescents with. JAACAP. 2007;46(11):1503-1526. Possible SSRI Side Effects Antidepressants: SNRIs ~3%-8% may have increased impulsivity, agitation, irritability, silliness, and "behavioral activation" Must differentiate from symptoms of mania/hypomania Suicidality venlafaxine (Effexor, Effexor XR ) desvenlafaxine (Pristiq ) duloxetine (Cymbalta ) milnacipran (Savella ); levomilnacipran (Fetzima ) Mechanism of Action: serotonin and norepinephrine levels S/E: significant withdrawal phenomenon hypertension suicidality Children and Adolescents with. JAACAP. 2007;46(11):1503-1526. Joel V. Oberstar, M.D. 5
Antidepressants: Others bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL ) Increases dopamine and norepinephrine S/E: rash, seizure threshold, suicidality mirtazapine (Remeron ) Increases norepinephrine and serotonin S/E: weight gain, sedation, suicidality trazodone (Desyrel ) S/E: sedation, priapism, suicidality Treatment in Adolescent Depression Study (TADS) 439 youth ages 12-17 with mod-severe MDD Prozac + CBT = 71% improved Prozac alone = 61% improved CBT alone = 43% improved Placebo = 35% improved 29% had SI prior to TADS <10% at 12 th week 5.5% suicide-related events 3.5% SSRI & 2% no med March J et al. Fluoxetine, Cognitive Behavioral Therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA 292(7), August 18, 2004, pp 807-820. Continuation Phase Treatment Given high rate of relapse (40-60%), continue treatment 6-12 months in all patients Continue medication Continue psychotherapy Consolidate skills learned Address intrapsychic, contextual factors, and environmental stressors that may contribute to relapse Maintenance Phase Treatment After 6-12 months symptom free, consider maintenance vs. discontinuation of treatment Favoring maintenance: 2 or 3 episodes (maintain 1-3 years) 2 episodes with psychosis, severe suicidality, treatment resistance (maintain longer) More than 3 episodes (maintain longer) When discontinuing medication, taper slowly Depressive Disorders. JAACAP. 1998;37(10 Supplement):63S-83S.. JAACAP. 1998;37(10 Supplement):63S-83S. The Black Box Warning in Pediatric Populations Antidepressants (can) increase risk of suicidality Must balance risks and benefits in prescribing Monitoring Physician Family and patient Dispense smaller quantities Clarify off-label use of medication Conclusions Pediatric depression comes in many forms MDD can be associated with significant morbidity and mortality is treatable with medication and psychotherapy Joel V. Oberstar, M.D. 6