Pediatric Mood Disorders

Child vs. Adult

More concrete conceptually

 Less competent linguistically (”sad” vs “depressed”)

 Less introspective than adults

 Don’t see the problems and don’t see the value of talking about it

 Become involved through the concern of parents and caregivers

 They are often less motivated to participate in treatment and to share common treatment goals with the clinician

Two Important Factors when working with children

1. The child's level of cognitive development

2. His/Her dependence on the others

Dependence on Others

Children seldom refer themselves for treatment

 Will need to work with others

 Parent, grandparent, caregiver, parole officer, teachers, daycare, and more

Words kids use to describe

depression:

 Blah

 Flat-lined

 Down

 Out of it

 Stressed

 Angry/Annoyed/Irritated/Mad

 I just don’t care

 Whatever

If they don’t use words they

show:

• Irritability

• Low frustration tolerance

• Temper tantrums

• Somatic complaints

• Hallucinations

• Social withdrawal

MDD Children SIGECAPS

S= Sleep changes

 I= Interest (loss)

 G= Guilt (worthlessness)

 E= Energy (lack)

 C= Concentration

 A= Appetite

 P= Psychomotor retardation or agitation

 S= Suicide

mdd in kids special considerations

Gender Difference:

 Equal rates among children

 Higher rates in female adolescents vs. male adolescents

 Children

 More Irritability, temper tantrums, low frustration tolerance, somatic complaints,

and/or social withdrawal

 Adolescents

 Show the above symptoms, but may have more melancholic symptoms and

suicide attempts

Comobidities and Lool A;ole Disorders in Pediatric MDD

Comorbidities:

 40-90% have a comorbidity and up to 50% have 2 or more comorbidities

 Anxiety Disorders

 Disruptive Disorders (ODD, CD)

 ADHD

 Substance Disorders (adolescence)

Look Alike Disorders:

 Medical Issues (Thyroid, steroids, mono, certain cancers)

 Irritability? Is it Bipolar? Is it ADHD? Is it anxiety? Are they using substances?

 Somatic concerns (Frequent HA, Stomachaches, etc)

 Demoralization from Learning Disabilities & ADHD

 Adjustment Disorders/Bereavement

Pediatric mdd etiology

 Nature

 Twin studies show its moderately heritable (40-60%)

 Children who have a first-degree relative with MDD are 3x as likely than those

without a family history

 5-HTTLPR (serotonin transpoter gene) short S-allele + early environmental stress

leads to higher levels of depression

 Thyroid dysfunction

 Nurture: Environmental Stressors

 Bullying, abuse, neglect, income inequality, racial/ethnic38 and other forms of

discrimination, and acculturation stress, parental death, parent-child conflict,

academic issues, and many more

Pharmacology for Pediatric MDD

Mild cases can use CBT or IPT

Moderate or Severe involves therapy and medication

FDA Approved for MDD in pediatrics

• fluoxetine(prozac) 8-18 years

• escitalopram 12-18

• Pther first line pptions are sertrialine and citalopram or SNRI (Venlafaxine)

FDA Black Box Warning for SSRI in children

Increased suicidality risk in children, adolescents, and young adults with MDD or other psychiatric disorders

 In studies it did not increase risk of suicide in patients >24

Bottom-Line for Pediatric MDD

There is evidence that cognitive-behavioral therapy (CBT), interpersonal

psychotherapy (IPT), and the selective serotonin reuptake inhibitor (SSRI)

antidepressants (in particular, fluoxetine) are efficacious for the treatment of

depressed youth. The combination of therapy plus antidepressants seems to

be more efficacious and to improve functioning for some depressed youth.

 Youth who do not respond to a trial with one SSRI (after 6-12 weeks) should

switch to another SSRI and add CBT

 If a second SSRI has not worked could consider an SNRI

 Could consider combination of medications (adding Buproprion (Wellbutrin) or

lithium to the SSRI) or ECT, but there is much less evidence for this

 Treatment should be continued for at least 6-12 months (but consider what is happening in their life when they stop)

 Assess meds at 4 week intervals

Mania in Childhood

Narrow definition

 Diagnose according to unmodified adult criteria

 Requires clearly defined episodes of mania

2. Broad definition

 Severe explosive irritability represents a prepubertal type of mania

 chronic, nonepisodic symptoms of irritability and hyperarousal

Diagnosis of BP

Often in Bipolar Disorder the first episode is depression-

therefore, we treat what we see

 In order to tell the difference look for

 “Who’s your Daddy?”

 Family History: Mood disorder, hospitalization, suicide, tx with

bipolar meds, ECT?

 “Where’s your mama?”

 Collateral information from family

 Specific to kids: current symptoms that make you suspect

bipolar spectrum: severe depressive episodes with psychosis,

hypersomnia and psychomotor retardation

 History of pharmacologically induced mania or hypomania

 However, 5-10% of people who take an SSRI become activated in general, without bipolar disorder

Mania in Pediatrics FDA Approved Meds

• Lithium 13+

• Aripiprazole (Abilify) 10+

• Risperidone (Risperidal) 10+

Course of Mania treatment in pediatrics

1st line: SGA, give it 4-8 weeks to work and then if it does not taper off over 1-2 weeks and simultaneously start another SGA. Try multiple SGAs before switching to another class

2nd line: If partial response to SGA add lithium. If no response to SGA, start lithium alone.

3rd line: Use a combination; anticonvulsant + lithium, SGA + anticonvulsant, FGA + anticonvulsant, FGA + lithium

Last resort....Clozaril or ECT

Pediatric treatment of Bipolar Depressive episodes

FDA Approved for bipolar depression: P;anzapine/fluoxetine combo or Lurasidone (Latoda)

Mild: If currently treated with antimanic/SGA add therapy, if not on antimanic agent start

antimanic agent + therapy

Moderate: SGA (Abilify, Latuda, Zyprexa, Seroquel, Risperdal- these are not all FDA

approved, but recommended per uptodate)- give it 1-2 weeks to work

Moderate to Severe: SGA + SSRI (Lexapro, Prozac, Zoloft-not FDA approved for

Bipolar depression, but recommended per uptodate) started simultaneously

FDA Approved Medications:

Pediatric Bipolar Maintenance

Lithium alone has not been successful in maintenance for BP for kids

 Lamotrigine (Lamictal) has some support but no FDA approval as it does in adults

 Some evidence for mania in kids, but none in adults

 No studies of the long-term effects of atypical antipsychotics

 Best strategy? Keep them on whatever made them go into remission for as long as you can, unless it is poorly tolerated

 If they had psychotic features and responded to combination treatment (SGA + lithium) continue both drugs for at least 2-6 months, but consider longer for patients who are severely ill (attempted suicide)

 If stable, could consider tapering off lithium and continuing SGA

 Also is suggested to continue treatment for 1-2 years, however some may need to continue medications indefinitely

Lithium Side Effects

Sedation, tremor, increased

urination, GI issues, N/V, HA

 No ibuprofen

Valproate SE

Kids are more susceptible to hepatic and pancreatic SE

 Immediate release is better tolerated than extended release

Lamictal SE

Stevens Johnsons Syndrome

 Start very low and go very slow

 Interacts with BCP

 Typically well tolerated

Carbamazepine

HA, Fatigue, Rash, white blood

cell count decreased, nausea,

and vomiting

 Decrease in YMRS from 29 to

13

 Extended release may be better

option

 P450 inducer

 Oxcarbazepine (Trileptal)

 No better than a placebo in some studies

Atypical Antipsychotics in children

All carry varying risk of metabolic side effects including: increased appetite, weight gain, diabetes, high cholesterol, hyperprolactemia

Diagnosis of Disruptive Mood Dysregulation Disorder (DMDD)

NON EPISODIC IRRITABILITY Severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation

The temper outbursts are inconsistent with developmental

level

treatment of DMDD based on symptons(ex, depression or anxiety symptoms use ssris, adhd use stimulants or bipolar looking use mood stabilizers)

Diagnosis of DMDD: OI VEY

O=Outbursts - frequent and impairing and in more than one place

 I= Irritable mood (when not having outbursts)

 V= Very Chronic - has lasted at least a year

 E= Explained by another condition (E.G. mania, MDD, PTSD, anxiety, ASD

 Y= Young - starts in childhood (after age 6, before age 10, not after 18)

Carlson, 2017