Pediatric Mood Disorders…and more!? · Neurodevelopmental Disorders Schizophrenia Spectrum & Other Psychotic Disorders ... Sleep – Wake Disorders Gender Dysphoria Disruptive,

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2019 Bryan Health Spring Primary Care Conference

Matt Wittry, D.O.Child and Adolescent PsychiatryBryan Heartland PsychiatryBryan Medical Center

Pediatric Mood Disorders…and more!?

Financial– Bryan Physician Network– No other financial interests/affiliations

Professional Memberships– AACAP (American Academy of Child and Adolescent Psychiatry)– APA (American Psychiatric Association)– AMA (American Medical Association)– Nebraska State Medical Association

Experience

Disclosures

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IOWEGIAN

Baguette??

Disclosures

Define and classify pediatric mood disorders

Recognize signs and symptoms of various mood disorders in youth

Understand and utilize treatment recommendations for various mood disorders in youth

Objectives

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DSM-IV-TR

– Mood - a pervasive and sustained emotional state that may affect all aspects of an individual’s life and perceptions.

– Mood Disorders - pathologically elevated or depressed disturbances of mood, and include full or partial episodes of depression or mania.

Classification Changes

DSM-IV-TR– Axis I Clinical Disorders Categories

Disorders usually first diagnosed in infancy, childhood, or adolescence Delirium , dementia , amnestic, and other cognitive disorders Medical disorders due to a general medical condition Substance-related disorders Schizophrenia and other psychotic disorders Mood Disorders Anxiety disorders Somatoform disorders Factitious disorders Dissociative disorders Sexual and gender identity disorders Eating disorders Sleep disorders Impulse control disorders not elsewhere classified Adjustment disorders


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DSM-IV-TR– Mood Disorders

10 specific mood disorders Sub-categories

– Depressive Disorders– Bipolar Disorders– Substance Induced– Due to AMC– NOS


DSM-5– Major Diagnostic Categories

Neurodevelopmental Disorders Schizophrenia Spectrum & Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive & Related Disorders Trauma and Stressor- Related Disorders Dissociative Disorders Somatic Symptom & Related Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria


Disruptive, Impulse- Control, and Conduct Disorders Substance-Related and

Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Disorders

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Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma and Stressor- Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse- Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Disorders



DSM-IV-TR– Axis I Clinical Disorders Categories

Disorders usually first diagnosed in infancy, childhood, or adolescence

Delirium , dementia , amnestic, and other cognitive disorders

Medical disorders due to a general medical condition

Substance-related disorders Schizophrenia and other psychotic

disorders Mood Disorders Anxiety disorders Somatoform disorders Factitious disorders Dissociative disorders Sexual and gender identity disorders Eating disorders Sleep disorders Impulse control disorders not elsewhere

classified Adjustment disorders


Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic

Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma and Stressor- Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse- Control, and Conduct

Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Disorders

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Mood – Mix of emotions and feelings– Semi-persistent mental + physical + emotional state– “How have you been feeling lately?”

Disorder (DSM-5 definition)– Clinically significant disturbance in cognition, emotion

regulation, and/or behavior that reflects a dysfunction in psychological, biological, or developmental processes underlying mental functioning

– Significant distress or disturbance in FUNCTION– Diagnosis of disorder ≠ need for treatment

Mood Disorders

Why is a broad definition salient for you today??

– 20% of US Children, age 9 – 17, have a diagnosable psychiatric disorder

– 20% of emotionally disturbed children and adolescents receive some kind of mental health services

– “Vast majority of these children receive services from primary care clinicians” (AAP.org)

Mood Disorders

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Why is a broad definition salient for you today??– YOU DO THE HEAVY LIFTING!! THANK YOU, THANK YOU,

THANK YOU!!!!

Mood Disorders

Why is a broad definition salient for you today??

Diagnosis drives treatment recommendations… Diagnosis impacts treatment efficacy…

Mood Disorders

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Suicide is the __________ leading cause of death for ages 10 - 24 years old?

– A. 4th

– B. 2nd

– C. 6th

– D. 1st

Quiz Question #1

Quiz Question #1

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Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Substance/Medication-Induced Bipolar and

Related Disorder Bipolar and Related Disorder Due to Another

Medical Condition Other Specified Bipolar and Related Disorder Unspecified Bipolar and Related Disorder

Bipolar and Related Disorders

Life time prevalence for children and adolescents =1% Manic episode

– Abnormally elevated, expansive, or irritable mood– Increased goal-directed activity or energy– ≥1 week duration, most of the day, nearly every daily– 3 or more DIGFAST

Distractibility Impulsive / irresponsible behavior Grandiosity Flight of ideas Activity level increased Sleep need is decreased Talkativeness

Preceded / followed by Hypomanic or Major Depressive Episode

Bipolar I Disorder

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Life time prevalence for children and adolescents =1% Hypomanic episode

– Abnormally elevated, expansive, or irritable mood– Increased goal-directed activity or energy– ≥ 4 days duration, most of the day, nearly every daily– 3 or more DIGFAST

Distractibility Impulsive / irresponsible behavior Grandiosity Flight of ideas Activity level increased Sleep need is decreased Talkativeness

Preceded / followed by Hypomanic or Major Depressive Episode

Bipolar II Disorder

Life time prevalence for children and adolescents <4% For ≥ 1 year, numerous periods of…

– Subthreshold hypomania < 3 DIGFAST < 4 days

– Subthreshold major depression < required symptoms or < required length of time

Periods have been present ≥ half the time Not without symptoms > 2 months at a time

Cyclothymic Disorder

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Treatment– REFER!!– Psychotherapy– Pharmacotherapy

Monotherapy– Second-generation antipsychotics– Lithium?

Combination– 2nd gen + lithium– 2nd gen + antiepileptic– Lithium + antiepileptic– 1st gen + lithium or antiepileptic

SSRIs??

Bipolar and Related Disorders

What is Nebraska’s state rank for suicide death rate?

– A. 12th

– B. 26th

– C. 34th

– D. 49th

Quiz Question #2

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Quiz Question #2

Disruptive Mood Dysregulation Disorder Major Depressive Disorder Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Substance/Medication-Induced Depressive Disorder Depressive Disorder Due to Another Medical Condition Other Specified Depressive Disorder Unspecified Depressive Disorder

Depressive Disorders

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Prevalence of ≈ 2-5%

Severe, recurrent temper outbursts– Manifested verbally and/or behaviorally– Disproportionate to stressor– Average ≥ 3 per week

Mood Component– Persistently irritable or angry– Most of the day, nearly everyday

Present in at least 2/3 settings for a duration >12 months

Dx 6-18yo, age at onset before 10yo

Co-occurs with MDD, ADHD, Anxiety Disorder, SUDs, and Conduct Disorder

CANNOT co-occur with ODD, IED, or Bipolar Disorder

Disruptive Mood Dysregulation Disorder (DMDD)

Treatment– Combination Treatment = Psychotherapy + Pharmacotherapy

– Pharmacotherapy Established treatment recommendations? No FDA approval What are you going after? Benefit vs. Risk analysis

– SSRIs– Antiepileptic (short list)– Non stimulants (alpha -2 agonists)– 2nd generation antipsychotic– Antiepileptic (the others)– Stimulants (long acting formulations)– Others (NO benzodiazepines)

DMDD

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Major Depressive Disorder– Prevalence increases through childhood and adolescence

Point prevalence of ≈ 5% Lifetime prevalence in adolescents (12-17 yo)= 11%

– Sex Ratio Adolescent F:M = 2:1 Pre-pubertal (≤12 yo) 60% higher prevalence in boys than girls

– Risk Factors + family history ACEs (abuse, neglect, early loss) Psychosocial stressors (BULLYING, academics, family) History of other psychiatric disorders Chronic illness

– Course Average duration = 8-13 mo, children, 4 -9 mo adolescents Recurrence in 20 – 70%


Major Depressive Disorder– Sad/Depressed or Irritable mood or– Diminished interest or pleasure– 5 or more present most of the day, nearly every day, for

2 weeks SIG E CAPS

– Sleep changes– Interest in pleasurable activities– Guilt– Energy– Concentration – Appetite– Psychomotor changes– Suicidal Thoughts

– No manic or hypomanic episodes


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Major Depressive Disorder Treatment

– Functional Change?

No…(but substantial effort is required to maintain function)– Non directive support, monitoring– If symptoms persist after 6-8 wks, then psychotherapy

and ? antidepressant

Yes…(progression, duration, severity, pt/family characteristics, comorbidity, )– Mild = Psychotherapy– Moderate – severe = Combination treatment



– Combination Treatment = Psychotherapy + Pharmacotherapy(CBT) (SSRI)

More effective compared to either alone (acutely only?) Pharmacotherapy > Psychotherapy ? 60% respond to initial treatment

– Pharmacotherapy SSRIs!! Start low and go slow… If at first you don’t succeed… If ain’t broke don’t fix it?? With psychosis?? Suicidality??


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– FDA in 2004 required Black Box Warning “antidepressants may increase the risk of suicidal

ideation and behavior in children and adolescents”Analyzed 24 trials, >4400 pts, 9 “antidepressants” 4% vs 2% increased risk of suicidalityNO increased suicidality if present, NO induction if not

– Association does not equal causality– Depression is one of the largest risk factors for suicide– Knowledge is power!


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Neurodevelopmental Disorders

Schizophrenia Spectrum and Other Psychotic Disorders

Anxiety Disorders

Obsessive – Compulsive Related Disorders

Trauma - and Stressor – Related Disorders

Somatic Symptom and Related Disorders

Feeding and Eating Disorders

Sleep – Wake Disorders

Gender Dysphoria

Disruptive, impulse – Control, and Conduct Disorders

Substance Related and Addictive Disorders

Neurocognitive Disorders

Personality Disorders

Other “Mood Disorder” Considerations

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Suicidality

Self Harm

School Avoidance

Social Media

Other “Mood Disorder” Considerations

Questions??

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Social Media

AACAP– https://www.aacap.org/AACAP/Resources_for_Primary_Care/Home.aspx

AAP Mental Health Screening and Assessment Tools for Primary Care– https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-

Health/Documents/MH_ScreeningChart.pdf

American Association of Suicidology– https://www.suicidology.org/

American Foundation for Suicide Prevention– https://afsp.org/about-suicide/suicide-statistics/

Healthy Children.org– https://www.healthychildren.org/English/Pages/default.aspx

Massachusetts Child Psychiatry Access Project– https://www.mcpap.com/

National Institute for Mental Health– https://www.nimh.nih.gov/index.shtml

National Network of Child Psychiatry Access Projects– https://nncpap.org/

Nebraska state suicide prevention coalition– http://www.suicideprevention.nebraska.edu/resourcesandlinks.htm

Suicide Prevention Resource Center– http://www.sprc.org/resources-programs

Resources

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AACAP Workforce Fact Sheet. 2014. American Academy of Child and Adolescent Psychiatry. Accessed from http://www.aacap.org/AACAP/Resources_for_Primary_Care/Workforce_Issues.aspx

American Psychiatric Association: Desk Reference to the Diagnostic Criteria From DSM-5. Arlington, VA, American Psychiatric Association, 2013.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.

Birmaher B, Brent D, AACAP Work Group on Quality Issues, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 2007; 46:1503.

Birmaher B, Axelson D, Pavaluri M. Bipolar Disorder. In: Lewis' Child and Adolescent Psychiatry: A comprehensive textbook, 4th ed., Martin MA, Volkmar FR, Lewis M (Eds), Lippincott Williams & Wilkins, London 2007.

Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA 2008; 299:901.

Highlights of Changes from DSM-IV-TR to DSM-5. Accessed from www.dsm5.org.

References

Integrated Primary Care. American Academy of Pediatrics (AAP) Children's Mental Health in Primary Care, E-Newsletter. Accessed from www.aap.org/mentalhealth.

Leading Causes of Death by Age Group, 2017. Centers for Disease Control and Prevention. Accessed from https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_by_age_group_2017_1100w850h.jpg

March JS, Silva S, Petrycki S, et al. The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. Arch Gen Psychiatry 2007; 64:1132.

Massachusetts Child Psychiatry Access Project. Accessed from www.mcpap.org.

Olfson M, Blanco C, Wang S, et al. National trends in the mental health care of children, adolescents, and adults by office-based physicians. JAMA Psychiatry 2014; 71:81.

State Fact Sheets, Nebraska 2019. American Foundation for Suicide Prevention. Accessed from https://afsp.org/about-suicide/state-fact-sheets/#Nebraska.

Van Meter AR, Moreira AL, Youngstrom EA. Meta-analysis of epidemiologic studies of pediatric bipolar disorder. J Clin Psychiatry 2011; 72:1250.

Zuckerbrot RA, Cheung AH, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics 2007; 120:e1299.

References