szigethy 2003

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Information about szigethy 2003

Published on February 27, 2008

Author: Dario


Mad or Sad?: Identifying & Treating Mood Disorders in Children & Adolescents:  Mad or Sad?: Identifying & Treating Mood Disorders in Children & Adolescents Eva Szigethy, MD, PhD Children’s Hospital Boston Harvard Medical School November 1, 2003 The Many Faces of Depression:  The Many Faces of Depression Depressed, Irritable or Angry Mood School, Social or Behavior Problems Substance Abuse Family Difficulties Elation, Mania Somatic Complaints DSM-IV Criteria for Adult Major Depression:  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 Depression in Pre-Schoolers:  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 Depression in School Age Children:  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 Atypical Depression in Adolescents:  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 Prevalence of Depression in Children and Adolescents:  Prevalence of Depression in Children and Adolescents Prevalence in general population 0.3-0.9% preschoolers (M=F) 1-2% school age (M>F) 4-8% adolescents (F>M) 2-12% adult (M) 5-26% adult (F) Prevalence in pediatric medical population 2-3x higher than general population Adolescent Depression:  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 Suicidality:  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 Risk Factors for the Onset of Depression:  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) When to Refer:  When to Refer When sadness/depression/anger compromises functioning Major shifts in friends, school, family Parents/patient feels overwhelmed Any question of self-harm Biopsychosocial Treatment Plan:  Biopsychosocial Treatment Plan Depression Pharmacotherapy Indications:  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 What Med to Choose?:  What Med to Choose? Consider side effect profile Consider drug interactions Consider compliance Consider safety Consider co-morbid conditions Consider family history Antidepressant Treatment:  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) SSRIs- Common Side Effects:  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 Atypical Antidepressants:  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 Major Depression Treatment Algorithm: Texas Project :  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, 38:1999) Beginning Antidepressants in Children:  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 BUT…Downside to Antidepressants in Youth:  BUT…Downside 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. Therapy Modalities:  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 Psychotherapy vs. Antidepressant Medication:  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 Change in CDI Score Over Time Post CBT:  Change in CDI Score Over Time Post CBT Assumptions of Cognitive Behavioral Therapy :  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 What is CBT?:  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 Weisz’s Skills and Thoughts Model:  Weisz’s Skills and Thoughts Model 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 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 ACT & THINK Chart:  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- Don’t Give Up Outline of CBT Sessions:  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. Case Presentation:  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 Working Hypotheses:  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. CBT skills most likely to help:  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 can’t 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. Four Promising Approaches to Treat Depression:  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 The Preventive Intervention Research Cycle:  The Preventive Intervention Research Cycle Oh, the Places You’ll Go! By Dr. Seuss:  Oh, the Places You’ll Go! By Dr. Seuss “Congratulations! Today is your day. You’re off to Great Places! You’re 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, don’t worry, Don’t stew. Just go right along, You’ll start happening too. And will you succeed? Yes! You will, indeed! Oh! The places you’ll go!”

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