1. Mood Disorders October 9, 2007

2. Mood Disorders Any disturbance in mood Any disturbance in mood Extreme, persistent, or poorly regulated emotional states Extreme, persistent, or poorly regulated emotional states Major Depressive Disorder Major Depressive Disorder Dysthymic Disorder Dysthymic Disorder Bipolar Disorder Bipolar Disorder

3. Major Depressive Disorder

4. Prior to 1970’s Before 1970's childhood depression was rarely discussed Before 1970's childhood depression was rarely discussed Children and depression? Children and depression? WHY? WHY?

5. Depression in Children One of the most disabling childhood disorders One of the most disabling childhood disorders Prevalence is increasing and age of onset is decreasing Prevalence is increasing and age of onset is decreasing Experience and expression changes with age Experience and expression changes with age Under age 7 tends  diffuse and less easily identified Under age 7 tends  diffuse and less easily identified

6. Developmental Course Age of onset usually between 13-15 years Age of onset usually between 13-15 years Average episode = 8 months Average episode = 8 months Often continue to experience adjustment and health problems and chronic stress Often continue to experience adjustment and health problems and chronic stress Gender differences: Gender differences: Pre-puberty: 50/50 Pre-puberty: 50/50 Post-puberty: Girls 2-3x more likely Post-puberty: Girls 2-3x more likely

7. Developmental Course of MDD Figure 8.1 Adapted from “Development of Depression from Preadolescence to Young Adulthood: Emerging Gender Differences in a 10-year-Longitudinal Study,” by B. L. Hankin, L. Y. Abramson, T. E. Moffitt, P. A. Silva, R. McGee & K. E. Andell, 1998, Journal of Abnormal Psychology, 107, 128-140. Copyright (c) 1998 by the American Psychological Association. Reprinted by permission of the author.

8. DSM-IV Criteria A depressed mood/sadness most of the day, most days depressed mood/sadness most of the day, most days diminished interest or pleasure in activities diminished interest or pleasure in activities changes in appetite or weight changes in appetite or weight sleep disturbances sleep disturbances psychomotor retardation or agitation psychomotor retardation or agitation fatigue or loss of energy fatigue or loss of energy feelings of worthlessness or inappropriate guilt feelings of worthlessness or inappropriate guilt difficulty thinking or concentrating difficulty thinking or concentrating thoughts of death or suicidal ideation thoughts of death or suicidal ideation

9. Criteria B-D B. The symptoms do not meet criteria for a Mixed Episode (Mania + Depression) C. The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning D. Symptoms are not due to the direct effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

10. Criteria E E. Symptoms are not accounted for by Bereavement; or the bereavement symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation

11. DSM-IV Criteria A depressed mood/sadness most of the day, most days depressed mood/sadness most of the day, most days diminished interest or pleasure in activities diminished interest or pleasure in activities changes in appetite or weight changes in appetite or weight sleep disturbances sleep disturbances psychomotor retardation or agitation psychomotor retardation or agitation fatigue or loss of energy fatigue or loss of energy feelings of worthlessness or inappropriate guilt feelings of worthlessness or inappropriate guilt difficulty thinking or concentrating difficulty thinking or concentrating thoughts of death or suicidal ideation thoughts of death or suicidal ideation

12. Prevalence & Comorbidity Prevalence: Prevalence: 2-8% of children ages 4-18 2-8% of children ages 4-18 more rare among preschool and school-age children, increases into adolescence and adulthood more rare among preschool and school-age children, increases into adolescence and adulthood Most common comorbid disorders are: Most common comorbid disorders are: anxiety disorders anxiety disorders dysthymia dysthymia conduct problems conduct problems ADHD ADHD substance use disorder substance use disorder

13. Dysthymic Disorder

14. Features: Features: less severe than MDD less severe than MDD less anhedonia, social withdrawal, impaired concentration, death thoughts, and physical complaints less anhedonia, social withdrawal, impaired concentration, death thoughts, and physical complaints more constant sadness, self-depreciation, low self- esteem, anxiety, irritability, anger, and temper tantrums more constant sadness, self-depreciation, low self- esteem, anxiety, irritability, anger, and temper tantrums “Double depression” “Double depression”

16. Prevalence & Comorbidity 1% of children and 5% of adolescents 1% of children and 5% of adolescents Most common comorbid disorder is MDD Most common comorbid disorder is MDD

17. Assessment

18. Assessment Multiple methods of assessment are critical Multiple methods of assessment are critical Older children better self-reporters Older children better self-reporters Self-report unhelpful before age 8 Self-report unhelpful before age 8 Parents may or may not have insight Parents may or may not have insight Obtain parent ratings of general child functioning Obtain parent ratings of general child functioning CBCL, BASC CBCL, BASC

19. Interview Interviews Interviews Parents, child interviewed separately Parents, child interviewed separately With child, cover With child, cover General and specific self-reports General and specific self-reports Discussion of mood and daily activities Discussion of mood and daily activities Suicidal ideation, behavior Suicidal ideation, behavior

20. Challenges in Assessment Younger children cannot describe their emotional experiences Younger children cannot describe their emotional experiences Caregivers limited reports of younger children’s internal states Caregivers limited reports of younger children’s internal states May reflect problems of parent rather than child May reflect problems of parent rather than child Lack of agreement between children, parents, and teachers on symptoms Lack of agreement between children, parents, and teachers on symptoms

21. Depression in Adolescents Depression in late adolescence may have some developmental distinctiveness Depression in late adolescence may have some developmental distinctiveness Common symptoms in adolescents include: Common symptoms in adolescents include: anhedonia (lack of pleasure) anhedonia (lack of pleasure) psychomotor retardation (slowing down) psychomotor retardation (slowing down)

22. Children’s Depression Inventory (CDI) Purpose: Purpose: It’s a 27 item self-report It’s a 27 item self-report measures depression in children and adolescents measures depression in children and adolescents Administration: Administration: 8-17 years 8-17 years 10-15 minutes to complete 10-15 minutes to complete

23. Reynolds Adolescent Depression Scale (RADS) Purpose: Purpose: It’s a 30 item self-report measure designed to assess depressive affective symptomatology in adolescents ages 13-18 It’s a 30 item self-report measure designed to assess depressive affective symptomatology in adolescents ages 13-18 It assesses clinically relevant levels of depressive symptomatology in individual adolescents It assesses clinically relevant levels of depressive symptomatology in individual adolescents

24. Suicide 3 rd leading cause of deaths in adolescents 3 rd leading cause of deaths in adolescents Suicide has quadrupled in adolescence in the last 50 years Suicide has quadrupled in adolescence in the last 50 years National Youth Risk Behavior Survey: National Youth Risk Behavior Survey: 24.1% - seriously considered attempting suicide 24.1% - seriously considered attempting suicide 17.7% - had a specific plan 17.7% - had a specific plan 8.7% - made an attempt 8.7% - made an attempt

25. Suicide Risk Factors Gender Gender History of depression History of depression Previous suicide attempt Previous suicide attempt Family hx of mental illness Family hx of mental illness Hx of sexual/physical abuse Hx of sexual/physical abuse Social isolation Social isolation Family disruption Chronic or debilitating illness Alcohol use Living out of the home Psychosocial problems Easy access to lethal methods Sexuality

26. Suicide Resources Alachua County Crisis Center Alachua County Crisis Center 24-hour telephone crisis intervention and counseling service 24-hour telephone crisis intervention and counseling service Mobile outreach team Mobile outreach team Survivors of Suicide support group Survivors of Suicide support group http://crisiscenter.alachua.fl.us/ http://crisiscenter.alachua.fl.us/ http://crisiscenter.alachua.fl.us/ 1(352) 264-6789 1(352) 264-6789 National Suicide Hotline National Suicide Hotline 1(800) SUICIDE 1(800) SUICIDE

27. Baker Act Florida Statute 394.467 Florida Statute 394.467 He or she has refused voluntary placement for treatment after sufficient and conscientious explanation and disclosure of the purpose of placement for treatment; or He or she is unable to determine for himself or herself whether placement is necessary; and

28. Baker Act Florida Statute 394.467 Florida Statute 394.467 He or she is manifestly incapable of surviving alone or with the help of willing and responsible family or friends, including available alternative services, and, without treatment, is likely to suffer from neglect or refuse to care for himself or herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; or

29. Baker Act There is substantial likelihood that in the near future he or she will inflict serious bodily harm on himself or herself or another person, as evidenced by recent behavior

30. Bipolar Disorder

31. Bipolar Disorder (BD) Features Features periods of abnormally and persistently elevated, expansive, or irritable mood, alternating with one or more major depressive episodes periods of abnormally and persistently elevated, expansive, or irritable mood, alternating with one or more major depressive episodes may display symptoms such as over-excitement, restlessness, agitation, sleeplessness, pressured speech, flight of ideas, sexual disinhibition, inflated self-esteem, reckless behavior may display symptoms such as over-excitement, restlessness, agitation, sleeplessness, pressured speech, flight of ideas, sexual disinhibition, inflated self-esteem, reckless behavior several DSM subtypes, based on whether youngster displays a manic, mixed, or hypomanic episode several DSM subtypes, based on whether youngster displays a manic, mixed, or hypomanic episode

33. Prevalence and Comorbidity of BP Lifetime estimates of 0.4%-1.2% Lifetime estimates of 0.4%-1.2% Extremely rare in young children, but increases after puberty (when rates are as high as for adults) Extremely rare in young children, but increases after puberty (when rates are as high as for adults) Affects males and females equally Affects males and females equally Most commonly comorbid with anxiety disorders, ADHD, conduct disorders, and substance abuse Most commonly comorbid with anxiety disorders, ADHD, conduct disorders, and substance abuse

34. Developmental Course of BP Peak age of onset between 15 - 19 years of age Peak age of onset between 15 - 19 years of age Depression usually appears first Depression usually appears first Chronic and resistant to treatment, with poor long-term prognosis Chronic and resistant to treatment, with poor long-term prognosis

35. Causes of BP In adults suggests: the result of a genetic vulnerability in combination with environmental factors (e.g., life stress, family disturbances) In adults suggests: the result of a genetic vulnerability in combination with environmental factors (e.g., life stress, family disturbances) Understudied in children!!! Understudied in children!!!

36. Treatment of BP Treatment must be multi-modal and often includes: Treatment must be multi-modal and often includes: education of the patient and the family about the illness education of the patient and the family about the illness medication, usually lithium medication, usually lithium psychotherapeutic interventions to address symptoms and related psychosocial impairments psychotherapeutic interventions to address symptoms and related psychosocial impairments

37. Treatment for Depression Medications Medications tricyclic antidepressant medications tricyclic antidepressant medications Fluoxetine (Prozac) Fluoxetine (Prozac) Antidepressants and suicide risk? Antidepressants and suicide risk? Prevention Prevention CBT is most effective at lowering risk for depression, as well as preventing recurrences CBT is most effective at lowering risk for depression, as well as preventing recurrences

38. Treatment for Depression Psychosocial Interventions Psychosocial Interventions Cognitive-behavioral therapy (CBT) Cognitive-behavioral therapy (CBT) Interpersonal therapy Interpersonal therapy