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Pediatric Mood Disorders…and more!? · Neurodevelopmental Disorders Schizophrenia Spectrum &...
Transcript of Pediatric Mood Disorders…and more!? · Neurodevelopmental Disorders Schizophrenia Spectrum &...
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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
Classification Changes
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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
Classification Changes
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
Classification Changes
Disruptive, Impulse- Control, and Conduct Disorders Substance-Related and
Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Disorders
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DSM-5– Major Diagnostic Categories
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
Classification Changes
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
DSM-5– Major Diagnostic Categories
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%
Depressive Disorders
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
Depressive Disorders
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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
Depressive Disorders
Major Depressive Disorder 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??
Depressive Disorders
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Major Depressive Disorder Treatment
– 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!
Depressive Disorders
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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