Wisconsin Alliance of Child Wisconsin Alliance of Child Psychiatry and PediatricsPsychiatry and Pediatrics
Teleconference on Depression Teleconference on Depression in Children and Adolescents in Children and Adolescents
October 12October 12thth 2010 2010
Wisconsin Alliance of Child Wisconsin Alliance of Child Psychiatry and PediatricsPsychiatry and Pediatrics
Psychiatry Course Director:Psychiatry Course Director: Joseph O’Grady Jr. M.D. FAAPJoseph O’Grady Jr. M.D. FAAP Associate Professor of Clinical PsychiatryAssociate Professor of Clinical Psychiatry Medical College of WisconsinMedical College of Wisconsin
Medical DirectorMedical Director Phoenix Care Systems IncPhoenix Care Systems Inc 414-955-8935 414-955-8935
WACPP teleconferenceWACPP teleconferenceSpeakers on depression:Speakers on depression: Kambiz Pahlavan M.D.Kambiz Pahlavan M.D. Medical Director Medical Director Rogers Memorial HospitalRogers Memorial Hospital 414-327-3000414-327-3000 Mark Siegel M.D.Mark Siegel M.D. Aurora Psychiatric HospitalAurora Psychiatric Hospital 414-454-6000414-454-6000
WACPP teleconferenceWACPP teleconferenceOutlineOutline Didactic presentation on depressionDidactic presentation on depression Case studies review – principles of Case studies review – principles of managementmanagement Question and answer sessionQuestion and answer session
WACPP teleconferenceWACPP teleconferenceTeleconference as an educational Teleconference as an educational
activity not as a specific case activity not as a specific case consultation activityconsultation activity
For a specific case consultation need, I For a specific case consultation need, I would refer you to a child and would refer you to a child and adolescent psychiatrist for a clinical adolescent psychiatrist for a clinical consultationconsultation
WACPP teleconferenceWACPP teleconferenceEducational goals for this presentation:Educational goals for this presentation: Know and apply diagnostic criteria for Know and apply diagnostic criteria for depression depression Know and apply the indications for Know and apply the indications for medication treatment of depressionmedication treatment of depression Know and apply indications for referral to a Know and apply indications for referral to a child and adolescent psychiatristchild and adolescent psychiatrist Know and apply the indications for Know and apply the indications for hospitalization for depressionhospitalization for depression Know and apply medication treatment options and Know and apply medication treatment options and monitoring for adverse medication effects monitoring for adverse medication effects
Depression in children and Depression in children and adolescents was misunderstood or adolescents was misunderstood or poorly recognized and treated until poorly recognized and treated until the late 1970s and early 1980s. To the late 1970s and early 1980s. To some extent we still don’t fully some extent we still don’t fully appreciate this illness.appreciate this illness.
Introduction
Depressed children were often labeled poorDepressed children were often labeled poorlittle sad thing, spoiled kid, mommy’s boy little sad thing, spoiled kid, mommy’s boy
ororgirl, cry baby, kid who can’t be satisfied, girl, cry baby, kid who can’t be satisfied,
badbadparenting, etc.parenting, etc.
The misconception was worse withThe misconception was worse withpreschool children.preschool children.
While we are in better shape today, still weWhile we are in better shape today, still weare far from accuracy.are far from accuracy.
Current criteria is predominantly adoptedCurrent criteria is predominantly adoptedfrom adult psychiatry research andfrom adult psychiatry research andconsensus. consensus.
However, research in children andHowever, research in children andadolescents has brought more descriptiveadolescents has brought more descriptiveclarity to the adopted symptomatology fromclarity to the adopted symptomatology fromadult psychiatry.adult psychiatry.
Epidemiology of Major Depression Epidemiology of Major Depression in Children and Adolescents:in Children and Adolescents:
Point prevalence in pre-pubertal children Point prevalence in pre-pubertal children is 1-2%is 1-2%
Point prevalence in adolescents is 3-8%Point prevalence in adolescents is 3-8%Lifetime prevalence by the end of Lifetime prevalence by the end of
adolescence is about 20%adolescence is about 20%
PM Lewinsohn, et all 1998PM Lewinsohn, et all 1998EJ Castello, et all 2003EJ Castello, et all 2003HZ Reinhertz, 1993HZ Reinhertz, 1993
Gender distribution of Major Gender distribution of Major Depression with the onset in puberty Depression with the onset in puberty shows a 3:1 dominance by females shows a 3:1 dominance by females
probably due to:probably due to:
1)1) Increase in estradiol and Increase in estradiol and testosteronetestosterone
2)2) Higher rate of anxiety and tendency Higher rate of anxiety and tendency for rumination in femalesfor rumination in females
3)3) Increase in interpersonal conflicts in Increase in interpersonal conflicts in adolescentsadolescents
Risk Factors:Risk Factors:
1)1) GeneticGenetic2)2) Cognitive distortions and negative view Cognitive distortions and negative view
of the self, future, and the worldof the self, future, and the world3)3) Family/Parental depression, criminality, Family/Parental depression, criminality,
substance abuse, lower education, lack substance abuse, lower education, lack of cohesion, and parent-child discordof cohesion, and parent-child discord
4)4) Environmental factors like: neglect, Environmental factors like: neglect, maltreatment, physical and sexual maltreatment, physical and sexual abuse, association with devious peers…abuse, association with devious peers…
5)5) Bereavement due to the loss of Bereavement due to the loss of sibling, parents, friends and other sibling, parents, friends and other significant peoplesignificant people
6)6) Poor connectedness to the family, Poor connectedness to the family, school, church, etcschool, church, etc
7)7) Provocative challenge of Provocative challenge of noradrenergic and serotonergic noradrenergic and serotonergic neuro-transmitter shows differences neuro-transmitter shows differences between depression prone children between depression prone children and non depressed ones.and non depressed ones.
8)8) Neuroimmaging: reduce volume of Neuroimmaging: reduce volume of left subgenual prefrontal cortex.left subgenual prefrontal cortex.
Steingard, et all showed decreased Steingard, et all showed decreased prefrontal cortex and increased third prefrontal cortex and increased third and fourth ventricular volume.and fourth ventricular volume.
McMillan reported increased pituitary McMillan reported increased pituitary and amygdala hippocompal ratio sizeand amygdala hippocompal ratio size
Thomas et all showed decreased Thomas et all showed decreased amygdala activation in depressed amygdala activation in depressed childrenchildren
Diagnostic Criteria for Diagnostic Criteria for Major Depression:Major Depression:
A.A. Five of the following nine symptoms Five of the following nine symptoms should be present in the same two weeks, should be present in the same two weeks, almost all day and nearly everyday. almost all day and nearly everyday. Symptom one and/or two has to be Symptom one and/or two has to be present.present.
1)1) Depressed mood by subjective reports or Depressed mood by subjective reports or others observations. In children and others observations. In children and adolescents it can be adolescents it can be irritableirritable mood mood instead of depressed.instead of depressed.
2)2) Markedly diminished interest or pleasure Markedly diminished interest or pleasure in all or almost all activities.in all or almost all activities.
3)3) Significant weight loss/gain without dietingSignificant weight loss/gain without dieting and/or decreased/increased appetite. Inand/or decreased/increased appetite. In children consider failure to make expectedchildren consider failure to make expected weight gains.weight gains.4)4) Insomnia/hypersomniaInsomnia/hypersomnia5)5) Psychomotor agitation/retardation (observablePsychomotor agitation/retardation (observable by others, not only subjective feeling)by others, not only subjective feeling)6)6) Fatigue or loss of energyFatigue or loss of energy7)7) Worthlessness, excessive or inappropriate guiltWorthlessness, excessive or inappropriate guilt8)8) Diminished ability to think or concentrate, orDiminished ability to think or concentrate, or indecisiveness indecisiveness 9)9) Recurrent thoughts of death, suicidal ideationsRecurrent thoughts of death, suicidal ideations with or without a plan, suicide attemptwith or without a plan, suicide attempt
B. Symptoms should cause significantB. Symptoms should cause significant distress or impairment in some important distress or impairment in some important areas of life.areas of life.C. Symptoms are not as a result of a C. Symptoms are not as a result of a medical condition (like hypothyroidism) ormedical condition (like hypothyroidism) or alcohol and drug abuse.alcohol and drug abuse.D. Symptoms are not better accounted for D. Symptoms are not better accounted for by bereavement, unless is longer than 2 by bereavement, unless is longer than 2 months or are characterized by marked months or are characterized by marked functional impairment, morbid functional impairment, morbid
preoccupationpreoccupation with worthlessness, suicidal ideation, with worthlessness, suicidal ideation,
psychoticpsychotic symptoms or psychomotor retardation.symptoms or psychomotor retardation.
Indication for Referral to a Indication for Referral to a Psychiatrist:Psychiatrist:
1)1) Diagnosis is not crystal clear because of co Diagnosis is not crystal clear because of co morbidities, severe parental confusion and morbidities, severe parental confusion and dispute about their symptoms, severe dispute about their symptoms, severe parental discord, discrepancies between what parental discord, discrepancies between what you see and what parents and school report, you see and what parents and school report, etcetc
2)2) Initial course of 2-4 weeks of conservative Initial course of 2-4 weeks of conservative medical treatment doesn’t cause an medical treatment doesn’t cause an appreciable improvement. Placebo effect of appreciable improvement. Placebo effect of any intervention is 40+%any intervention is 40+%
3)3) Patient’s symptoms are getting worse in Patient’s symptoms are getting worse in spite of adequate treatment.spite of adequate treatment.
4)4) Initial course of 2-3 months of Initial course of 2-3 months of psychotherapy hasn’t fostered psychotherapy hasn’t fostered appreciable stability.appreciable stability.
5)5) Recurrence of the symptoms in spite of Recurrence of the symptoms in spite of adequate treatment.adequate treatment.
6)6) Numbers of people in the family are Numbers of people in the family are having serious psychopathology.having serious psychopathology.
7)7) If you are not interested in treating If you are not interested in treating children with affective instability.children with affective instability.
8)8) Serious risk of suicide, homicide, and Serious risk of suicide, homicide, and destruction of propertydestruction of property
Indication for HospitalizationIndication for Hospitalization1)1) SuicidalitySuicidality2)2) HomicidalityHomicidality3)3) Aggression which is hard to manage at Aggression which is hard to manage at
home, school or on playground, and home, school or on playground, and may risk the safety of the patient and may risk the safety of the patient and others, and the property.others, and the property.
4)4) The patient who has been resistive to The patient who has been resistive to adequate treatment and continues to adequate treatment and continues to deteriorate.deteriorate.
Medication TreatmentMedication TreatmentFDA approved medications for treatment of FDA approved medications for treatment of
children and adolescents with major children and adolescents with major depression:depression:
Fluoxetine/prozac age 8-18Fluoxetine/prozac age 8-18Escitalopram/lexapro ages 12-17Escitalopram/lexapro ages 12-17
All others are ‘off-label’ although some have All others are ‘off-label’ although some have research evidence to support useresearch evidence to support use
sertraline/zoloftsertraline/zoloft citalopram/celexacitalopram/celexa
Medication treatment Medication treatment High placebo response with High placebo response with
antidepressantsantidepressants med response placebo resmed response placebo resFluoxetine 56% 35%Fluoxetine 56% 35%Citalopram 47% 45%Citalopram 47% 45%Escitalopram 64% 53%Escitalopram 64% 53%Sertraline 63% 53%Sertraline 63% 53%
Medication treatmentMedication treatmentTreatment of Adolescents with Depression Study (TADS)Treatment of Adolescents with Depression Study (TADS)Predictive of positive response:Predictive of positive response: younger ageyounger age less chronically depressedless chronically depressed higher functioninghigher functioning less hopelessless hopeless less suicidal ideationless suicidal ideation less melancholic symptomsless melancholic symptoms fewer co-morbid disordersfewer co-morbid disorders more expectation for improvementmore expectation for improvement
Medication treatmentMedication treatmentPredictors of suicidal events:Predictors of suicidal events: higher levels of suicidal ideation at higher levels of suicidal ideation at baselinebaseline minimal improvement of depressive minimal improvement of depressive
symptomssymptoms at least a moderate degree of depressionat least a moderate degree of depression acute interpersonal conflictacute interpersonal conflict
Medication treatmentMedication treatmentBox warning on antidepressantsBox warning on antidepressants depression is associated with an depression is associated with an
increase increase in risk of suicidein risk of suicide monitor appropriately and observe monitor appropriately and observe closely for clinical worsening, suicidal closely for clinical worsening, suicidal thinking, or unusual changes in thinking, or unusual changes in behaviorbehavior
Medication treatmentMedication treatment
Since FDA warnings, antidepressant use Since FDA warnings, antidepressant use has declined by 10% overall, with has declined by 10% overall, with decrease 40% by primary care providersdecrease 40% by primary care providers
Meta-analysis of 27 med treatment trials Meta-analysis of 27 med treatment trials of major depression in pediatric of major depression in pediatric population:population:
number to treat: 10number to treat: 10 number to harm 112number to harm 112
Medication treatmentMedication treatmentSSRI dosing:SSRI dosing: Fluoxetine 10-40 mgFluoxetine 10-40 mg Escitalopram 10-20 mgEscitalopram 10-20 mg Citalopram 10-60 mgCitalopram 10-60 mg Sertraline 25-150 mgSertraline 25-150 mg
Mediation treatmentMediation treatmentCommon side effects:Common side effects: nauseanausea headacheheadache vomitingvomiting dizziness dizziness sedationsedation decreased appetitedecreased appetite dry mouth dry mouth withdrawal effects: nausea, headaches, muscle withdrawal effects: nausea, headaches, muscle
aches, aches, parathesiasparathesias
Medication treatmentMedication treatmentTreatment progression:Treatment progression: Start with SSRIStart with SSRI if response continue for 1 yearif response continue for 1 year if no response, switch or augmentif no response, switch or augment SwitchSwitch use different SSRI and cross taper use different SSRI and cross taper
dosesdoses use buproprion (Wellbutrin)use buproprion (Wellbutrin) use dual acting agent: venlafaxine use dual acting agent: venlafaxine (Effexor) or duloxetine (Cymbalta)(Effexor) or duloxetine (Cymbalta)
Medication treatmentMedication treatmentAugment with:Augment with: buproprion (Wellbutrin)buproprion (Wellbutrin) buspirone (Buspar)buspirone (Buspar) lithiumlithium thyroidthyroid aripiprazole (Abilify)aripiprazole (Abilify)
Summary slideSummary slidePediatric depression focus Pediatric depression focus diagnostic criteria revieweddiagnostic criteria reviewed indications for medication treatmentindications for medication treatment indications for child and adolescent indications for child and adolescent
psychiatrist psychiatrist referralreferral indications for hospitalizationindications for hospitalization medication treatment options medication treatment options medication adverse effects monitoring medication adverse effects monitoring
Case reviewsCase reviews
Questions and answer Questions and answer sessionsession
