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Mad or Sad: Identifying

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Complaints of feeling 'bored', loss of interest. Temper tantrums ... Report feeling 'stupid', 'down', 'bored' Change in motivation/social withdrawal ... – PowerPoint PPT presentation

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Title: Mad or Sad: Identifying


1
Mad or Sad? Identifying Treating Mood
Disorders in Children Adolescents
  • Eva Szigethy, MD, PhD
  • Childrens Hospital Boston
  • Harvard Medical School
  • November 1, 2003

2
The Many Faces of Depression
  • Depressed, Irritable or Angry Mood
  • School, Social or Behavior Problems
  • Substance Abuse
  • Family Difficulties
  • Elation, Mania
  • Somatic Complaints

3
DSM-IV Criteria for Adult Major Depression
  • Persistent depressed/irritable mood
  • Change in sleep
  • Change in appetite/weight
  • Fatigue
  • Decreased concentration
  • Psychomotor change
  • Anhedonia
  • Worthlessness
  • Thoughts of death/suicidality
  • Guilt
  • Hopelessness

4
Depression in Pre-Schoolers
  • Intense separation anxiety/neediness
  • Attention seeking
  • Dysphoria, irritability, crying spells
  • Somatic complaints
  • Regressive behavior
  • Sleep/appetite disturbance
  • Apathy in play or exploration
  • Spending much time crying/rocking

5
Depression in School Age Children
  • Somatic complaints common
  • Poor school performance
  • Irritability, social withdrawal, inability to
    cope with minor frustrations
  • Complaints of feeling bored, loss of interest
  • Temper tantrums
  • Boys- negativism, aggression, conduct problems
  • Girls- behavioral inhibition, withdrawal

6
Atypical Depression in Adolescents
  • Mood reactivity- mood brightens with positive
    events
  • Dysphoria without stating their feelings or
    volatile mood
  • Report feeling stupid, down, bored
  • Change in motivation/social withdrawal
  • Increased appetite/increased sleep
  • Decreased performance in school, chores, sports
  • Intense self-consciousness/body concerns/low self
    esteem
  • Rejection sensitivity
  • Excessive fatigue/Leaden Arms/Legs

7
Prevalence of Depression in Children and
Adolescents
  • Prevalence in general population
  • 0.3-0.9 preschoolers (MF)
  • 1-2 school age (MF)
  • 4-8 adolescents (FM)
  • 2-12 adult (M) 5-26 adult (F)
  • Prevalence in pediatric medical population
  • 2-3x higher than general population

8
Adolescent Depression
  • Increase rates of depression post-puberty with
    change in sex ratio
  • 20-25 of adolescents have at least one
    depressive episode by age 18
  • 40-70 of depressed youth have a co-morbid
    psychiatric disorder

9
Suicidality
  • 8 of high school students make serious attempts
    each year (CDC, 1997)
  • 13/100,000 completed suicides each year in
    adolescents
  • Risk factors
  • Depression
  • Substance abuse
  • Poor social adjustment/recent arguments
  • Loss of parent
  • Family Discord

10
Risk Factors for the Onset of Depression
  • Parent with mood disorder- both genetics and
    environment
  • Severe stressors (loss, parental conflict,
    trauma, school failure, peer rejection, or
    physical illness)
  • Low self-esteem, low self-efficacy, hopelessness,
    helplessness
  • Being female
  • Being in a disadvantaged position (economic,
    ethnic, social)

11
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12
When to Refer
  • When sadness/depression/anger compromises
    functioning
  • Major shifts in friends, school, family
  • Parents/patient feels overwhelmed
  • Any question of self-harm

13
Biopsychosocial Treatment Plan
14
Depression Pharmacotherapy Indications
  • Sufficiently severe to interfere with functioning
  • Severe depression neurovegetative or suicidal
  • History of recurrent depression that does not
    respond to psychotherapy
  • Psychotic or bipolar depression
  • Positive antidepressant response for depression
    in first degree relatives
  • Comorbid psychiatric disorders

15
What Med to Choose?
  • Consider side effect profile
  • Consider drug interactions
  • Consider compliance
  • Consider safety
  • Consider co-morbid conditions
  • Consider family history

16
Antidepressant Treatment
  • Tricyclic Antidepressants (NE SE)
  • Serotonin Selective Reuptake Inhibitors (SE)
  • Atypical Antidepressants
  • Wellbutrin (DA NE)
  • Effexor (NE SE)
  • Serzone (5HT-2 antagonist)
  • Remeron (5HT2,3 antagonist)

17
SSRIs- Common Side Effects
  • CNS stimulation
  • Insomnia, anxiety, agitation, nervousness
  • Manic activation
  • Sexual side effects decreased libido
    anorgasmia
  • Gastrointestinal symptoms, nausea
  • Tremor
  • Weight loss/gain

18
Atypical Antidepressants
  • Buproprion- seizures, appetite decrease,
    agitation, tics
  • Venlafaxine- sedation, nausea, HTN
  • Nefazadone- liver toxicity, sedation, dry mouth
  • Mirtazapine weight gain, sedation
  • Trazadone- sedation, priapism

19
Major Depression Treatment Algorithm Texas
Project
  • Non-medication options
  • SSRI
  • Alternative SSRI partial augment (Li, Buspar)
  • Alternative Class
  • Combination (TCA SSRI, BUP SSRI)
  • MAO Inhibitors
  • ECT (Hughes et al, JAACAP, 381999)

20
Beginning Antidepressants in Children
  • Use trial of psychotherapy first and continue
    during med trial to address environmental,
    psychological and social problems associated with
    depression
  • Inform parents about risks, dose, time course of
    benefits, risks of overdose, and drug-drug
    interactions
  • Start low dose and go slow
  • If first episode, good recovery, minimal family
    history, continue 9-12 months after response
  • If severe, prolonged first episode, major family
    history, few side effect, continue 1-3 years

21
BUTDownside to Antidepressants in Youth
  • Long-term developmental impact and effectiveness
    of SSRIs is not determined in this population.
  • Rates of SSRI-induced manic episodes may be as
    high as 20.
  • Often antidepressants do not work in youth-
    possibly due to developing chemical systems in
    brain
  • Recent studies implicating paroxetine (Paxil) and
    venlafaxine (Effexor) in increased suicidal
    thoughts and agitation in adolescents, though
    causality not proven.

22
Therapy Modalities
  • Psychodynamic Therapy
  • Translate unconscious motives for behaviors into
    words in the context of a human relationship
  • Cognitive Behavioral Therapy (CBT)
  • Problem oriented treatment that seeks to identify
    and change maladaptive beliefs and behaviors
  • Interpersonal Therapy (IPT)
  • Grief, interpersonal disputes, role transitions,
    interpersonal deficits
  • Family Therapy

23
Psychotherapy vs. Antidepressant Medication
  • Psychotherapy
  • CBT effective for treatment of uncomplicated
    depression
  • CBT has been shown to be effective in the
    longer-term prevention of relapse in major
    depression.
  • Antidepressants
  • May be more useful for more severe depression.
  • More rapid onset of action than psychosocial
    interventions.
  • Can be useful if co-morbid anxiety disorder or
    eating disorder is present

24
Change in CDI Score Over Time Post CBT
25
Assumptions of Cognitive Behavioral Therapy
  • Emotions, thoughts and behaviors are connected
    and interact with environment
  • Based on adult models proposing skill deficits or
    deviant cognitive structure in adult repertoires
  • Adolescent social skills and repertoires less
    stable
  • Adolescents more influenced by environment
    (modeling, prompting, rewarding, punishing)
  • Under stress, maladaptive processing systems are
    activated/primed

26
What is CBT?
  • Identifying mood/mood monitoring
  • Pleasant activity scheduling
  • Behavioral problem solving
  • Relaxation/guided imagery
  • Target negative cognitive distortions
  • Communication skills/conflict resolution
  • Social skills training
  • Humor to cognitively reframe
  • Develop long-term goals

27
Weiszs Skills and Thoughts Model
  • Gain control over mood by developing skills to
    cultivate primary and secondary control
  • Primary control changing objective conditions
    to make them fit wishes
  • Secondary control changing expectations to
    adjust to objective conditions and thus control
    their subjective impact
  • Skill deficits and cognitive habits may generate
    sad affect in response to adverse stressful or
    ambiguous life events
  • Skill deficits poor activity selection, poor
    self-soothing, un-engaging social style
  • Cognitive Habits negative cognitions,
    rumination, perceived helplessness hopelessness,
    lack of control

28
ACT THINK Chart
  • A Activities
  • C Calm Confident
  • T Talents
  • T Think Positive
  • H Help from a
  • Friend
  • I Identify the Silver
  • Lining
  • N No Replaying
  • Bad Thoughts
  • K Keep Trying-
  • Dont Give Up

29
Outline of CBT Sessions
  • Session 1 Introduce PASCET, learn problem
    solving approach
  • Session 2 Choosing activities that you enjoy
  • Session 3 Activities with others, improving
    interpersonal skills
  • Session 4 Relaxation techniques including guided
    imagery
  • Session 5 Showing positive self- improving
    social skills
  • Session 6 Developing talents and skills
  • Session 7 Addressing negative cognitive
    distortions
  • Session 8 Addressing negative cognitive
    distortions about physical illness
  • Session 9 Positive reframing and practicing
    social skills
  • Session 10-12 Review of skills learned and
    personalizing skills.

30
Case Presentation
  • 14 y.o. white female
  • New onset x 3 months of feeling sad, easily
    frustrated, decreased motivation and energy, I
    hate myself, and stomach aches
  • Downward shift of grades, isolated from friends,
    and decreased after-school activities
  • Has inflammatory bowel disease with abdominal
    pain
  • Coping with parental tension
  • Mother with depression, father often critical

31
Working Hypotheses
  • Skills and Thoughts Model
  • C has a number of skill deficits including social
    withdrawal, poor self-soothing abilities in the
    face of perceived rejection from peers, poor
    selection of reinforcing activities, decline in
    academic skills.
  • C has a number of maladaptive cognitive habits
    such as lack of perceived control over her
    environment, negative cognitive distortions, and
    distorted self image.
  • Together these negative behaviors and thoughts
    make her more vulnerable to feeling depressed.

32
CBT skills most likely to help
  • Teach coping skills to elicit PRIMARY control
  • Scheduling fun activities alone and with others
  • Relaxation to help counter pain
  • Showing more positive self in social situations
  • Teach ways to change thinking in situations that
    cant be changed to elicit SECONDARY control
  • Thinking less negatively by identifying cognitive
    distortions and replacing with more positive
    thoughts
  • Mood monitoring to link emotions, thoughts and
    behaviors.

33
Four Promising Approaches to Treat Depression
  • Cognitive behavioral preventions for those with
    major risk signs- Clarke
  • Classroom and school-based preventions for those
    already showing some symptoms-Seligman
  • Public health family-based prevention approaches-
    Beardslee
  • Identifying, treating, and preventing depression
    in adolescents with physical illness- Szigethy

34
The Preventive Intervention Research Cycle
35
Oh, the Places Youll Go! By Dr. Seuss
  • Congratulations! Today is your day. Youre off
    to Great Places! Youre off and away!
  • You have brains in your head. You have feet in
    your shoes. You can steer yourself any direction
    you choose.
  • Out there things can happen and frequently do to
    people as brainy and footsy as you. And when
    things start to happen, dont worry, Dont stew.
    Just go right along, Youll start happening too.
  • And will you succeed? Yes! You will, indeed!
  • Oh! The places youll go!
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