Mood disorders

F31–F34

DEPRESSION IN CHILDHOOD AND ADOLESCENCE

F32-34

DESCRIPTION

The clinical picture of a child and adolescent with major depressive disorder is similar to that of adults except that there are some developmental differences i.e.:

  • mood is often irritable rather than sad
  • failure to gain weight, rather than weight loss
  • somatic complaints e.g. headaches and abdominal pain
  • behavioural and academic/school problems occur frequently
  • withdrawal from social activities
  • vegetative symptoms are less common than in adults
  • suicide attempts increase in number, tend to be more lethal and
  • impairment of functioning worsens with increasing age

The first episode of bipolar disorder can present with depression in adolescents. Bipolar depression is often associated with a more sudden onset, psychomotor retardation, anxiety symptoms, and in some instances, psychotic symptoms and a family history of bipolar disorder.

A number of depressed children and adolescents have co-morbid psychiatric disorders. The most frequent co-morbid diagnoses are:

  • Anxiety disorders
  • ADHD
  • Oppositional defiant disorder,
  • Conduct disorder and
  • Substance misuse, particularly in adolescents

Conduct problems may develop as a complication of the depression and persist after the depression remits. It is important to assess and manage conditions that occur together with depression.

DIAGNOSTIC CRITERIA (DSM 5)

The clinical presentation of major depressive disorder includes 5 symptoms present for a period of 2 weeks and represents a change from previous functioning. Changes in either mood or interests must be present:

  • depressed mood reported or observed by others
  • decreased pleasure or interest in activities
  • vegetative symptoms including sleep/appetite disturbances
  • fatigue/loss of energy
  • poor concentration/indecision
  • psychomotor agitation/retardation
  • excessive, inappropriate guilty ruminations or feelings of worthlessness
  • thoughts of death and suicide, suicide attempt or suicide plan

Symptoms causes distress or impairment in functioning.
Exclude other psychiatric disorders, medical conditions, the effects of substances and manic/hypomanic episodes.

A suicide attempt is self-inflicted harm where the intention is to die.
Increased suicide risk is associated with the following:

  • male gender
  • adolescence
  • previous attempts and lethality of method used
  • family history of suicide
  • presence of a psychiatric or chronic medical illness
  • social isolation and poor family support
  • associated substance abuse or physical aggression

Consider the following in a child presenting with depressed mood:

  • Exclude underlying medical conditions such as:
    • infections, e.g. HIV, cerebral cysticercosis, encephalitis and tuberculous meningitis;
    • neurological conditions, e.g. temporal lobe epilepsy, brain tumours;
    • endocrine disorders, e.g. thyroid conditions, diabetes mellitus.
  • Exclude medication-induced mood disturbances e.g. corticosteroids, antiretroviral (zidovudine, efavirenz), high doses of stimulant medication and barbiturates.
  • Exclude substance abuse, including alcohol and methamphetamine (‘tik’).
  • Assess for suicide risk.

GENERAL AND SUPPORTIVE MEASURES

  • Psychological interventions are considered ‘first line’ for mild to moderate depression and should be administered by a suitably skilled clinician:
    • cognitive behavioural therapy (CBT): to address distorted, negative cognitions, maladaptive patterns of behaviour and communication;
    • Psychodynamic/play therapy: to identify feelings, improve self- esteem and social interactions.
  • Additional interventions:
    • family counselling: to address family disharmony, stressors and provide psycho-education;
    • input to school: to address academic issues and psycho-education;
    • Social worker: to investigate suspicion of child abuse or neglect.

MEDICATION TREATMENT

  • If there is a failure to respond to psychotherapeutic interventions after 4–6 weeks or if the severity of symptoms increases, consider a trial of antidepressant medication, while still continuing with psychotherapy and other interventions. Initiate treatment in consultation with a psychiatrist. Children 12 years and under should be referred to a child psychiatrist for the initiation of medication.
  • Response to treatment should bring about a meaningful reduction in symptoms and improvement in functioning.
  • Once remission is achieved continue medication therapy for at least a further 6–12 months.

First line:

  • Fluoxetine, oral, 0.5 mg/kg/day.

    However, fluoxetine may only be available in 20mg capsules, in which case citalopram tablets can be used initially, titrated to 20mg and then changed to fluoxetine 20mg if that dose has been reached.
    • Dose range: 20–40 mg daily
    • Recommended average dose: 20 mg/day

If there is a poor response to fluoxetine after an adequate trial of treatment i.e. 4–6 weeks, or if significant symptoms of anxiety are present or if the child is HIV infected; consider an alternative SSRI.

  • Citalopram, oral, 0.4 mg/kg/day
    • Dose range: 5–40mg daily
    • Recommended average dose: 10–20 mg/day

A trial of treatment is considered to be ineffective if the patient presents with ongoing, significant depressive symptoms and/or suicidal ideation and where the patient has not achieved an improvement in overall level of functioning.

Be aware of the risk of bipolar ‘switch’ or precipitation of mania in patients with a family history of bipolar disorder.

Tricyclic antidepressants are not recommended in children, due to insufficient evidence of efficacy, potential adverse cardiovascular side effects and lethality in overdose.

REFERRAL

  • Poor response to an adequate trial of treatment i.e. medication trial of 6–8 weeks in combination with psychological treatment and psychosocial interventions.
  • Presence of co-morbid conditions.
  • Psychotic symptoms such as delusions or hallucinations.

BIPOLAR DISORDER

F31

DESCRIPTION

The bipolar disorder presentation in children and adolescents differs from the adult discrete manic or depressive episodes. They usually present with mixed mood states and significant mood lability that fluctuates within a day resembling a rapid cycling pattern and rage attacks or ‘affective storms’.

Short-lived episodes of exuberance are normative in children and adolescents, while temper outbursts and mood lability can present in many other psychiatric disorders e.g. anxiety disorders, autism spectrum disorder (ASD). There is a risk of misdiagnosis or ‘over-diagnosis’ of bipolar disorder in children and adolescents presenting with severe aggression and ‘dysregulated’ moods.

DIAGNOSTIC CRITERIA (DSM 5)

Manic Episode

A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy. This should represent a significant change in the patient’s baseline mental status, last for at least 1 week and be present, most of the day, nearly every day.
During the period of mood disturbance, the patient should display the following symptoms:

  • Elevated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative than usual or pressured speech
  • Flight of ideas or feeling that thoughts are racing
  • Distractibility
  • Increased goal-directed activity (socially, at school or hyper-sexuality) or psychomotor agitation
  • Involvement in activities with potentially painful consequences e.g. sexual indiscretions

Depressive episode

Similar to symptoms of major depressive episode except that the onset may be more rapid and may be associated with psychomotor retardation, anxiety symptoms and/or psychotic symptoms.

Mixed mood state

This includes the presence of a major depressive episode with at least 3 manic/hypomanic symptoms present during the depressive episode. These are more common in children and adolescents.

Causes distress or impairment in functioning. Exclude other psychiatric disorders, medical conditions, the effects of substances and manic/hypomanic episodes

MEDICATION TREATMENT

Acute phase treatment

  • Refer patients with a suspected manic episode or suicidal ideation to a psychiatrist immediately for assessment and possible admission.
  • Sedate before transfer. Refer to Sedation of an acutely disturbed child or adolescent.
  • If no previous medication used, while awaiting admission and in consultation with a psychiatrist, initiate atypical antipsychotic and mood stabilizer:

Atypical antipsychotic:

  • Risperidone, oral.

5-12 years (under 50kg):

  • Starting dose: 0.01 mg/kg/day.
  • Maintenance dose: 0.02 - 0.04 mg/kg/day.

13-17 years:

  • Starting dose: 0.5 mg daily.
  • Maximum dose: 3 mg daily.
  • Use lowest effective dose to limit adverse long-term side effects and to facilitate adherence.
  • Increase dose by 0.25–0.5 mg daily every 1–2 weeks, depending on tolerability and age.

Mood stabiliser: lithium carbonate or sodium valproate:

  • Lithium carbonate: oral (for patients aged 12-17 years).
    • Initial dose 20 mg/kg/day in 2-3 divided dosages. Lithium level after 5 days. Increase accordingly. Therapeutic range 0.6-0.8 mmol/l. Be careful of narrow therapeutic margin-risk of toxicity.
    • Ensure investigations prior to initiation of treatment.
    • Blood investigations: FBC, U&E, CMP, TSH and BHCG.
    • Cardiac investigation includes: ECG.
    • Ongoing monitoring: lithium levels 1-3 monthly: TSH and creatinine 6-12 monthly.
  • Sodium valproate: oral.
    • 20 mg/kg/day: divided 12 hourly.
    • Usual range: 20-30 mg/kg/day.

Maintenance treatment

  • If previously on maintenance medication: re-initiate treatment in consultation with a psychiatrist.
  • Ongoing psycho-education regarding the illness, medication, compliance etc.
  • Once stabilised, the patient can be referred for individual psychotherapy.
  • The family may benefit from referral for family therapy.

REFERRAL

  • Refer all patients with suspected bipolar disorder for an assessment by a psychiatrist.
  • Sedate or stabilise prior to transfer.

DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD)

F34.81

DESCRIPTION

This is a new addition to DSM 5. Children and adolescents present with a history of chronic, severe, persistent irritability. The irritability presents as frequent temper outbursts with an underlying angry, irritable mood. The onset of symptoms is before 10 years and should not be applied to children with a developmental age less than 6 years. Conversion of non-episodic irritability to bipolar disorder is low. They are at higher risk of developing depressive and anxiety disorders in adulthood.

Important to consider the differential diagnoses. These include:

  • Mood disorders e.g. MDD, bipolar disorder
  • Behavioural disorders e.g. oppositional defiant disorder (ODD); anxiety disorders
  • Neurodevelopmental disorders e.g. ADHD, autism spectrum disorder (ASD) and
  • Impulse control disorders e.g. intermittent explosive disorder.

DIAGNOSTIC CRITERIA (DSM 5)

  • Temper outbursts that are severe and recurrent that manifest verbally or behaviourally, are out of proportion in intensity and duration to the situation or provocation, are inconsistent with the developmental level and occur > 3 times per week.
  • The mood between the temper outbursts is persistently irritable or angry for most of nearly every day and is observable by others.
  • Symptoms must be present for > 12 months with symptom-free periods that do not exceed 3 months.
  • Occurs in > 2 settings and is severe in at least one setting.
  • Age of diagnosis: 6-17 years.
  • Age of onset of symptoms <10 years.
  • Exclude psychiatric disorders, medical conditions and the effects of substance use.
  • There are high rates of comorbidity that include disruptive behavioural disorders, mood disorders, anxiety disorders and autistic spectrum disorders. If children meet the oppositional defiant disorder or intermittent explosive disorder criteria with DMDD, then only the DMDD diagnosis is given.

Functional consequences

DMDD is associated with significant functional impairment in all areas of their lives due to their extremely low frustration tolerance. This has a severe impact on family and peer relationships, academic performance and participation in extra-mural activities.

MEDICATION TREATMENT

Currently no specific treatment guidelines exist due to the lack of studies. Many patients present with ADHD and DMDD. The ADHD can be treated with methylphenidate but worsening of the mood may occur with severe aggression.

REFERRAL

  • Co-morbid DMDD should be referred to a psychiatrist.