MOOD, DEPRESSION AND SUICIDE IN YOUTHS: AN UPDATE

1. MOOD, DEPRESSION AND SUICIDE IN YOUTHS: AN UPDATE GARDY P. MUNOZ, MD Pediatric and Adult Psychiatrist Catawba Valley Medical Center Sept 2017

2. MOOD DISORDERS • Major Depressive Disorder • Bipolar Affective Disorder

3. Mood Disorders Appears in children of all ages Core features same in youth and adults except for features modified to match age and maturity of individual Two criteria for mood disorders are: -disturbance of mood (depression or elation) -irritability

4. Etiology • Genetic factors • Mood disorders cluster in same families • One depressed parent doubles risk for their children • Both parents depressed quadruples the risk • Social factors • Identical twins don’t have 100% concordance • Children with parent dying before age 13 • Some evidence with parental marriage, divorce, socio-economic status, abuse and neglect

5. Etiology • Biological factors • Hormonal level abnormalities • Reduced sleep REM latency • MRI low frontal lobe volume with high ventricular volume • Neurochemical factors • Low norepinephrine release • Low levels of serotonin • Abnormalities in the dopamine pathways

6. MOOD DISORDERS Major depression

7. Major Depression • Younger children • Somatic complaints • Social withdrawal • Sad appearance • Low self-esteem • Auditory hallucinations • Less melancholia • School refusal • Failure to gain weight • Older children • Anger • Pervasive anhedonia • Motor retardation • Delusions • Hopelessness • Behavioral changes • Social withdrawal

8. Major Depression • Seen in both younger and older children • Depressed or irritable mood • Insomnia • Diminished ability to concentrate • Suicidal ideations (age appropriate)

9. Major Depression-Specifiers • Melancholic Features • Loss of pleasure and lack of reactivity • Depression worse in mornings • Early morning awakening • Marked psychomotor changes • Anorexia or weight loss • Excessive guilt • Classically responds to TCA

10. Major Depression-Specifiers • Atypical Features • Mood reactivity is present • Hypersomnia • Increase appetite or weight gain • Leaden paralysis • Sensitivity to interpersonal rejection • Classically responds to MAO-I

11. Major Depression-Specifiers • Psychotic Features • Delusions are more common than hallucinations • Symptoms may be mood congruent or incongruent • Catatonia • Stupor, Mutism, Negativism • Catalepsy/Waxy Flexibility • Echolalia/Echopraxia/Stereotypy

12. Course: Depression • Depends of age of onset, severity of episodes and presence of comorbidities • Mean length of depressive episodes almost 8 months • Recurrence of 20-40% in 1-2 years • Recurrence of 70% in 5 years • Continued high levels of conflict more relapses • Majority will have symptoms in adulthood

13. Course: Depression • Risk of suicide represent 12% of mortalities in adolescents • 20-40% of adolescents with Major Depression may develop to Bipolar Disorder • Higher risk of developing Bipolar • Delusional thinking • Psychomotor retardation • Family history of Bipolar Disorder

14. Epidemiology: Depression • Mood disorders increase with increasing age • Prevalence in any age group is higher in psychiatrically referred group • Pre-school: 0.3% in community, 0.9% in clinic settings • School age: 2% in the community • Adolescents: 4-8% of the population • Hospitalized youth: 20% children; 40% of adolescents

15. Epidemiology: Depression • Lifetime prevalence by age 18 is approximately 20% • More than 70% of youths with depression do not get diagnosed or treated • Male: female ratio • 1:1 childhood • 1:3 adolescence

16. Epidemiology: Depression • Studies in adults suggest that each generation since 1940 is at greater risk for developing depressive disorders • Earlier onset with each successive generation

17. Comorbidity: Depression • 50-90% of depressed youths have other psychiatric diagnoses. • Most frequent comorbidities • Anxiety • Disruptive Behavioral Disorders • ADHD • Substance Use Disorder

18. Differential Diagnosis: Depression • Bereavement • Depressive reaction to stressors • Substance/medication induced depression • Stimulants • Steroids • Contraceptives

19. Differential Diagnosis: Depression • Bipolar Disorder • Significant family history • Psychotic symptoms • History of medication induced mania • Hypomanic symptoms

20. MOOD DISORDERS BIPOLAR DISORDER

21. Bipolar Disorder • Diagnosis utilizes same criteria for adults • Most often present with mixed episodes and mixed features • Primarily irritability and explosiveness • Chronic impairment that can represent baseline functioning

22. Epidemiology: Bipolar Disorder • Preschool validity has not been established • May take years to be diagnosed • Mania typically appears for the first time in adolescent years • Genetics • 4-6 fold increased risk of mania in first degree relatives

23. Epidemiology: Bipolar Disorder • Lifetime rate: 0.6% of adolescents in the community • Childhood Prevalence Estimates • 0.1% - 1.0% • Episode of mania : 0.1% • General Population Prevalence • Bipolar I Disorder: 1.6% • Bipolar II Disorder: 0.5%

24. Comorbidity: Bipolar Prevalence • ADHD 49-87% • Substance Abuse 8-39% • Panic Disorder 19-26% • GAD 19% • Social Anxiety 40% • ODD 75% • Conduct Disorder 12-41%

25. DMDDDisruptive Mood Dysregulation Disorder • Chronic irritability with frequent explosive outbursts • Outbursts disproportionate to situation • Not episodic or situation dependent • Condition starting after age 6 and before age 10  • Seen in multiple settings

26. MOOD, DEPRESSION AND SUICIDE IN YOUTHS: AN UPDATE Psychopharmacological Treatment

27. Medication Use in Children and Adolescents • Recent advances in the use of medications in youth population • Medications are used of target symptom reduction • Most medications are not FDA approved for this population • Widely used in Pediatric Psychiatry • Risks and benefits explored • Informed consent from guardian

28. Medication Use in Children and Adolescents • Children has greater liver capacity, faster kidney filtration and less fatty tissues • Half-life of medications are shorter • Medications need to be readjusted periodically because of increasing size of the patients

29. Medication Use in Children and Adolescents • Black Box Warning: • In 2004, the FDA has required that boxed warning be placed on all antidepressant medications warning that they may result in increased risk of suicidal tendencies in children, adolescents and young adults aged 18-24 years old. • Meta-analyses of 100,000 patients showed suicidal thinking in 4% of patients on antidepressants vs 2% on placebo.

30. MOOD, DEPRESSION AND SUICIDE IN YOUTHS: AN UPDATE SUICIDE

31. Suicide • Prepubescent child suicide is rare • Completed suicide Boys 5X > Girls • Attempted suicide Girls 3X > Boys • Suicidal ideations waxes and wanes • Suicidal behaviors are often impulsive • Over half of all suicides due to firearm

32. Suicide • 20% of teens seriously contemplated suicide • 8% attempt suicide • Suicide ranking by age as cause of death and suicide rate • Age 5-14: #5 (0.6/100,000) • Age 15-24: #3 (9.7/100,000)

33. Risk Factors: Suicide • History of prior attempts • Substance abuse • Disruptive Behavioral Disorder • Impulsivity and Aggression • Exposure to negative events • Availability of lethal agents • Personal history of suicidal behaviors • Family history of suicide

34. Risk Factors: Suicide • Male higher risk than females • Among females • Previous suicide attempts • Associated mood disorder • Bullying • Among males: • Previous suicide attempts • Age 16 and older • Associated mood and substance use

35. Etiology • Inability to synthesize solutions to problems • Lack of coping strategies to deal with immediate stressors • Genetic factors • Biological factor-low serotonin • Social factors

36. Greatest Risks For Suicide Suicide History - Still thinking of suicide - Has made a prior suicide attempts Demographics - Male - Poor social support - Bullying

37. Greatest Risks For Suicide • Mental state • Depressed, manic, hypomanic, severely anxious of have a mixture of these states • Substance abuse alone or in association with a mood disorder • Irritable, agitated, threatening violence to others, delusional or hallucinating

38. HOW SUICIDE OCCURS AND HOW IT COULD BE PREVENTED

39. Checklist Before Discharge Caution patient and family about disinhibiting effects of drugs/alcohol Check that firearms and lethal medications can be secured Check that there is a supportive person at home Check that a follow up appointment has been scheduled

40. SALAMAT PO AND THANK YOU