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Depression in Children and Adolescents

(3-24-15)

Facets of depression

Depression (like anxiety, anger, and other emotional states) can be thought of in different ways (and hence measured in different ways)

  • Physiological–how our body reacts when we are depressed
  • Behavioral–how we act when we are depressed
  • Cognitive–how we think when we are depressed
  • Phenomenology (subjective)–how we feel when we are depressed

Level of analysis

  • Depression as a symptom
  • Depression as a syndrome
  • Depression as a disorder

Mood Disorders

  • Major Depressive Disorder
  • A Major Depressive episode that persists two weeks and causes significant personal distress or functional impairment
  • Major Depression: 5 of 9 symptoms which must include either:
    • Depressed mood nearly every day for most of the day, or irritable mood in children and adolescents or
    • Anhedonia (diminished interest in or pleasure from activities)
    • plus as least three or four (for a total of at least 5) of:
      • insomnia or hypersomnia nearly every day
      • significant weight loss or gain, increase or decrease in appetite nearly every day, or failure to gain expected weight in children
      • psychomotor agitation or retardation [observed, not reported]
      • fatigue or low energy nearly every day
      • feeling worthless or excessive guilt nearly every day
      • difficulty concentrating or indecisiveness nearly every day
      • recurrent thoughts of death or suicide
    • last at least two weeks, and cause either suffering or impairment in functioning
  • Dysthymia
    • Chronic (at least 2 years in adults, 1 year in children), milder depression than Major Depressive Disorder
      • but, dysthymia in children predicts a future episode of major depression
  • Bipolar Disorder
    • A Manic Episode that persists one week and causes either significant personal distress or functional impairment
    • Manic Episode: period of elevated, expansive, or irritable mood including 3 of 7 symptoms (not just poor temper control: “I snap out”)
  • Cyclothymia
    • Chronic (2 years in adults, 1 year in children) of mood swings, milder than Major Depression or Mania
  • Morbidity
    • suffering
    • impairment
  • Comorbidity
    • Anxiety Disorders
    • Substance Use Disorders
    • other mental disorders
  • Mortality–suicide

Pediatric Bipolar Disorder

  • Bipolar Disorder
    • mood disorder affecting 1 to 3.9 % of adult population (Bipolar I & II)
    • possibly most heritable major mental disorder
    • untreated episodes progressively more severe and treatment resistant
  • Bipolar Disorder in Children
    • less common: .4 to 1.2% prevalence for any bipolar; BP II, BP NOS, & cyclothymia more common
      • most common DSM-IV diagnosis in children: Bipolar Disorder Not Otherwise Specified (because did not meet duration criteria for either BP I or BP II)
    • “most comorbid” disorder: 99% of the time there is a second diagnosis
    • Modal Child Presentation: ultra-rapid cycling and comorbid ADHD, “rage attacks” most common presenting symptom
    • DSM-5 attempts to address the over diagnosis of bipolar disorder in youth (and attendant skyrocketing rates of prescriptions of neuroleptic medications) by introducing new diagnositic category:
      • Dysphoric Mood Disregulation Disorder, within the Depressive Disorders grouping
      • the impact of this new diagnosis remains to be seen
  • Differentiation of PBD and ADHD
    • most useful symptoms:
      • elevated mood
      • grandiosity/inflated self-esteem
      • pressured speech
      • racing thoughts
      • decreased need for sleep
      • hypersexuality
    • less useful
      • bizarre appearance
      • lack of insight
    • aggression probably most impairing symptom
      • highly sensitive
      • not very specific
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