Depressive and Bipolar Disorders

Overview of Mood Disorders

• Mood disorders span a spectrum from severe depression to extreme mania.
• DSM-5 divisions:
  • Depressive disorders: excessive unhappiness (dysphoria) and loss of interest in activities (anhedonia).
  • Bipolar disorder: mood swings from deep sadness to high elation (euphoria) and expansive mood (mania).

Depression in Young People

• Depression is a pervasive unhappy mood disorder that is more severe than typical blues or mood swings.
• In children, depression interferes with daily routines, social relationships, school performance, and overall functioning; often accompanied by anxiety or conduct disorders; frequently overlooked and untreated.
• Suicide among teens is a serious concern; about 90% of youngsters with depression show significant impairment in daily functions.

History of Childhood Depression

• Historically, it was believed depression did not exist in children in a form comparable to adults.
• Current understanding:
  • Children do experience recurrent depression.
  • Depression in children is not masked; it may be overlooked and frequently co-occurs with other disorders.

Depression in Young People: Developmental Expression

• Almost all young people experience some symptoms of depression at some time.
• Common presentation: lasting depressed mood with disturbances in thinking, physical functioning, and social behavior.
• Developmental differences in expression:
  • 0-7 years: depression tends to be diffuse and hard to identify; anaclitic depression (Spitz) observed in infancy.
  • Infants raised in emotionally cold institutional environments show depression-like reactions; similar symptoms can appear in infants from severely disturbed families.
  • Preschoolers: may be somber, tearful, excessively clingy to mothers.
  • School-age children: irritability, disruptive behavior, tantrums in addition to somber mood.
  • Preteens: self-blame, low self-esteem, persistent sadness, social inhibition.

Anatomy of Depression (Symptom, Syndrome, Disorder)

• Depression (symptom): feeling sad or miserable; can occur without a serious problem and is common at all ages.
• Depression (syndrome): group of symptoms that occur together more often than by chance; mixed symptoms of anxiety and depression clustering on a single negative affect dimension.
• Depression (disorder): major depressive disorder (MDD) or dysthymic disorder (persistent depressive disorder) with specific criteria.

Major Depressive Disorder (MDD)

• Diagnosis in children uses the same criteria as school-age children and adolescents.
• Depression can be overlooked because other behaviors attract attention; some features (e.g., irritable mood) are more common in youth.

Major Depressive Disorder (1 of 5): Diagnostic Criteria

• TABLE 10.1: Diagnostic Criteria for Major Depressive Disorder
• (A) Five (or more) of the following symptoms have been present during the same $2 ext{ -week period}$ and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms attributable to another medical condition.
• (B) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• (C) The episode is not attributable to the physiological effects of a substance or to another medical condition.

Major Depressive Disorder (2–4): Symptom Criteria (A items)

• (1) Depressed mood most of the day, nearly every day, as indicated by subjective report or observation; in children/adolescents, irritable mood may be present.
• (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
• (3) Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day. (In children, consider failure to gain weight.)
• (4) Insomnia or hypersomnia nearly every day.
• (5) Psychomotor agitation or retardation (not clearly shown in the transcript but part of DSM criteria).
• (6) Fatigue or loss of energy nearly every day.
• (7) Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
• (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day.
• (9) Recurrent thoughts of death, suicidal ideation, or a suicide attempt or plan.

Major Depressive Disorder (4 of 5): Criteria (B–E) (as summarized)

• (B) Clinically significant distress or impairment in social, occupational, or other functioning.
• (C) The episode is not attributable to substances or another medical condition.
• Note: Bereavement-related symptoms may resemble a depressive episode, but the presence of a major depressive episode in addition to a normal grief response requires careful clinical judgment.
• (D) The onset is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
• (E) Never been a manic or hypomanic episode (this exclusion does not apply if manic-like episodes are substance-induced or due to a medical condition).

Prevalence of Depression

• Between 2 ext{ -}8 ext{ ext{ %}} of children aged $4-18$ experience MDD.
• Depression is rare among preschool and school-age children (about 1-2 ext{ ext{ %}}); increases two- to threefold by adolescence.
• The sharp adolescent rise may result from puberty-related biological maturation interacting with developmental changes.

Comorbidity (Depression)

• Up to 90 ext{ ext{ %}} of youth with depression have one or more other disorders; about 50 ext{ ext{ %}} have two or more.
• Common comorbidities include: anxiety disorders (especially GAD), specific phobias, separation anxiety, dysthymia, conduct problems, ADHD, substance-use disorder.
• About 60 ext{ ext{ %}} of adolescents with MDD have comorbid personality disorders, particularly borderline personality disorder.
• Pathways to comorbidity may differ by disorder and sex.

Onset, Course, and Outcome (Depression)

• Onset may be gradual or sudden; usually a history of milder episodes that do not meet criteria.
• Typical age of onset: $13-15$ years.
• Average episode lasts about $8$ months.
• Longer duration if a parent has a history of depression.
• Most children recover from the initial episode, but recurrence risk is:
  • 25 ext{ ext{ %}} within one year,
  • 40 ext{ ext{ %}} within two years,
  • 70 ext{ ext{ %}} within five years.
• About one-third develop bipolar disorder within five years after onset of depression (bipolar switch).
• Overall prognosis is not optimistic.

Gender, Ethnicity, and Culture

• No gender differences prior to puberty; after puberty, females are two to three times more likely to suffer from depression.
• Symptom presentation is similar across sexes, but correlates differ.
• Physical, psychological, and social changes relate to the emergence of sex differences in adolescence.

Persistent Depressive Disorder (P-DD) / Dysthymia

• Characterized by depressed mood on most days for at least $1 ext{ year}$, with at least two somatic or cognitive symptoms.
• Symptoms are less severe but more chronic than MDD.
• Associated with poor emotion regulation: constant sadness, feelings of being unloved, self-deprecation, low self-esteem, anxiety, irritability, anger, temper tantrums.
• Children with both MDD and P-DDare more severely impaired than those with a single disorder.

Prevalence and Comorbidity for P-DD

• Prevalence: about 1 ext{ ext{ %}} in children and 5 ext{ ext{ %}} in adolescents.
• Most common comorbid disorder is MDD; about 70 ext{ ext{ %}} of children with P-DD experience a major depressive episode.
• About 50 ext{ ext{ %}} of children with P-DD also have one or more nonaffective disorders (e.g., anxiety disorders, conduct disorder, ADHD) that preceded dysthymia.

Onset, Course, and Outcome (P-DD)

• Most common age of onset: $11-12$ years.
• Childhood-onset dysthymia tends to be longer in duration (typically $2-5$ years).
• Most recover, but are at high risk for developing other disorders: MDD, anxiety disorders, conduct disorder.
• Adolescents with P-DD report less social support than those with MDD.

Associated Characteristics of Depressive Disorders

• Intellectual and academic functioning:
  • Difficulties with concentration, loss of interest, and slowed thinking/movements can lower test scores, teacher ratings, and grade attainment.
  • Interferes with academic performance, but not necessarily due to intellectual deficits.
  • Tasks requiring attention, coordination, and speed may be affected.
• Cognitive biases and distortions:
  • Selective attentional biases and negative beliefs about self, world, and future.
  • Depressive rumination, pessimistic outlook, negative self-esteem.
  • Generalized negative thinking, hopelessness, and suicidal ideation.
• Social, Peer, and Family Problems:
  • Few close friendships, loneliness, isolation; social withdrawal and ineffective coping.
  • Families: more critical/punitive toward the depressed child; parental depression can impair meeting child’s needs.
  • Higher risk of depression, phobias, panic, and alcohol dependence in adolescence/adulthood when parents are depressed.
• Depression and suicide:
  • Most think about suicide; up to one-third who think about it attempt it.
  • Common methods in completed suicides include firearms, hanging, suffocation, poisoning, overdose.
  • Worldwide risk factors: mood disorder and being a young female; peak ages for first attempt around $13-14$ years.

Theories of Depression (Overview Table)

• Psychodynamic: loss of love object (actual or symbolic) with anger turned inward; excessive superego; loss of self-esteem.
• Attachment: insecure early attachments; distorted internal working models of self and others.
• Behavioral: lack or loss of reinforcement; deficits in skills needed to obtain reinforcement.
• Cognitive: depressive mindset; maladaptive cognitive structures; negative view of self/world/future; hopelessness; poor problem-solving; self-blame.
• Self-Control: problems in organizing behavior toward long-term goals; deficits in self-monitoring and self-reinforcement.
• Interpersonal: impaired interpersonal functioning due to grief, role disputes, transitions, social withdrawal, and parenting factors.
• Socio-environmental: stressors and daily hassles as vulnerability factors; social support and coping as protective factors.
• Neuro-biological: neurochemical/receptor abnormalities; neurophysiological, neuroendocrine changes; genetic variants; structural/functional brain abnormalities.

Theories of Depression (2 of 3 and 3 of 3)

• Be sure to note the summary relationships among: information processing, negative cognitive triad (self, world, future), cognitive schemata, and depressive symptoms.
• Visual cue from the text: Devalue world, devalue self, devalue future (a schematic of Beckian cognitive vulnerability).

Developmental Framework for Depression

• Developmental framework emphasizes interactions among:
  • Genetic/neurobiological processes/temperament
  • Interpersonal competence
  • Family experiences
  • Emotion regulation/dysregulation
  • Life stress
  • Core beliefs about self and others
• Outcome: Depression emerges from intertwined influences rather than a single cause.

Genetic and Family Risk

• Twin studies suggest moderate genetic influence; heritability estimates 30 ext{%} to 45 ext{%}.
• Children of parents with depression have about a threefold increased risk of depression.
• Inherited vulnerability interacts with environmental stressors to express depression/anxiety.

Neurobiological Influences

• Brain regions involved in emotion regulation show abnormalities: amygdala, cingulate, prefrontal cortex, hippocampus.
• Other neurobiological findings: cortical thinning in the right hemisphere; HPA axis dysregulation; sleep abnormalities; variants in BDNF; abnormalities in serotonin, dopamine, and norepinephrine.

Family Influences

• When children are depressed: families show more critical/punitive behavior toward the depressed child.
• When parents are depressed: parenting quality declines, reducing ability to meet child’s needs; elevated risk for child depression, phobias, panic, and alcohol problems later.

Stressful Life Events

• Triggers for depression include: interpersonal stress and losses (death, abandonment); life changes (e.g., moving); violent family environment; daily hassles.

Emotion Regulation

• Prolonged distress or exposure to maternal negativity can impair regulation of negative emotions.
• Affected children may rely on avoidance or negative coping rather than problem-focused strategies.

Treatment of Depression (1 of 2)

• Fewer than half of depressed children receive help; disparities by racial/ethnic background.
• Cognitive-Behavioral Therapy (CBT) has shown the most success for youth depression.

Treatment of Depression (2 of 2)

• Interpersonal Psychotherapy for Adolescent Depression (IPT-A) focuses on improving interpersonal communication and is effective.
• Psychopharmacological treatments: SSRIs can be effective but have side effects including suicidal thoughts/self-harm; long-term brain effects less well understood.
• Overall, SSRIs are used with caution; many youth respond to placebo in some studies (placebo response up to about 60%).

Treatments for Depression (Summary Table: TABLE 10.3)

• Behavioral Therapy: increases positive reinforcement; reduces punishment; may teach social/ coping skills; includes anxiety management and relaxation.
• Cognitive Therapy: helps youth identify and modify pessimistic thoughts and causal attributions of self-blame.
• Cognitive-Behavioral Therapy (CBT): most common psychosocial intervention; integrates behavioral and cognitive approaches; attribution retraining sometimes used.
• Interpersonal Psychotherapy for Adolescent Depression (IPT-A): examines family/interpersonal dynamics; combines individual sessions.
• Medication: antidepressants (notably SSRIs).

Psychosocial Interventions (1 of 2)

• Behavior therapy: increase pleasurable activities; build reinforcement opportunities; skills training.
• Cognitive therapy: identify, challenge, modify negative thought processes.

Psychosocial Interventions (2 of 2)

• CBT: integrated behavioral and cognitive techniques; most common psychosocial approach.
• IPT-A: focuses on depressive symptoms within social/interpersonal context.

Medications (1 of 2)

• Tricyclic antidepressants have failed to show advantage over placebo in youth and carry potentially serious cardiovascular side effects.

Medications (2 of 2)

• SSRIs (e.g., fluoxetine, sertraline, citalopram) are most commonly prescribed for childhood depression; efficacy supported but side effects include suicidal thoughts/self-harm and uncertainties about long-term effects on developing brain.
• Placebo response can be substantial (~60 ext{ ext{%}} in some studies).

Prevention

• CBT and IPT-A are most effective at reducing risk and preventing recurrences.
• School-based initiatives can enhance protective factors and resilience; however, recent studies on prevention programs show mixed or non-significant results.

Bipolar Disorder (BD)

• BD features a striking period of unusually elevated, expansive, or irritable mood, alternating with or accompanied by one or more major depressive episodes.
• Elation/euphoria can rapidly shift to anger/hostility if behavior is impeded; mania can occur concurrently with depression.

Bipolar Disorder in Young People

• BP youth show significant impairment, including prior hospitalization, MDD, medication treatment, co-occurring disruptive behavior, and anxiety disorders.
• History of psychotic symptoms and suicidal ideation/attempts are common.

Bipolar Disorder Symptoms and Types

• Symptoms: restlessness, agitation, sleeplessness, pressured speech, flight of ideas, racing thoughts, sexual disinhibition, surges of energy, expansive grandiose beliefs.
• Subtypes:
  • Bipolar I disorder
  • Bipolar II disorder
  • Cyclothymic disorder

Mania in Young People

• Mania in youth can present with atypical symptoms: volatile mood, psychomotor agitation, mental excitement.
• Irritability, belligerence, and mixed manic-depressive features are more common than pure euphoria.
• Classic mania signs include pressured speech, racing thoughts, and flight of ideas.

Prevalence and Course (BD)

• Lifetime prevalence estimates range from 0.5 ext{ ext{%}} to 2.5 ext{ ext{%}} among youths aged 7–21.
• In youth, bipolar II and cyclothymic disorder are more common than bipolar I.
• Rapid cycling episodes are common.
• BD is extremely rare in young children; rate increases after puberty and becomes closer to adult rates.

Comorbidity and Associated Problems (BD)

• High rates of co-occurring disorders: separation anxiety, generalized anxiety, ADHD, oppositional/ conduct disorders, substance use disorders, and suicidality.
• Co-occurring medical problems can include cardiovascular/metabolic disorders, epilepsy, migraines.

Onset, Course, and Outcome (BD)

• About 60 ext{%} have a first episode before age 19; onset before age 10 is extremely rare.
• Adolescents with mania often present with psychotic symptoms, unstable moods, and severe deterioration in behavior.
• Early-onset BD tends to be chronic and treatment-resistant; long-term prognosis is poor.

Causes (BD)

• Limited pediatric research; adult data suggests a genetic vulnerability (e.g., BP-parent associated brain changes) interacting with environmental factors (life stress, family disturbances).
• Multiple genes may be involved; genetic predisposition does not guarantee development.
• Brain imaging suggests mood fluctuations relate to abnormalities in emotion-regulation networks including prefrontal and anterior cingulate cortex, hippocampus, amygdala, thalamus, and basal ganglia.

Treatment of Bipolar Disorder

• No cure currently exists.
• Multimodal treatment plan includes:
  • Close symptom monitoring
  • Education for patient and family
  • Individualized treatment matching (psychiatric, psychosocial interventions, etc.)
  • Medication management (e.g., lithium)
  • Addressing psychosocial impairments with psychotherapy