. Affective Disorders and Suicide

Affective Disorders and Suicide


 

Laura Prager, Steven C. Schlozman, and Michael Jellinek


 

Some experiences of sadness, grief, or depressed mood arise during the course of most children’s lives. Divorces, the death of a grandparent, the departure of a close friend, or a failed hope—all are common and upsetting. However, there has been increasing recognition that some children and adolescents suffer from serious and pervasive disorders related to their mood and that these disorders are associated with significant morbidity (ie, impairment in psychosocial function, low self-esteem) and mortality (ie, intended suicide or “accidental” death secondary to an impulsive behavior such as driving while intoxicated). Consequently, the critical clinical task is to differentiate children and adolescents with serious disorders from the larger group of children and adolescents who have some symptoms of sadness or grief but who are not clinically depressed. Since the diagnosis and risk assessment depends on emotional information gleaned from an interview, it can be extremely difficult for a clinician to differentiate between those children and adolescents with serious mood disorder and those who are profoundly and acutely upset in response to a combination of adverse circumstances.


Because our understanding of the patho-physiology of emotional dysregulation is just emerging, diagnosis of major depressive disorders relies primarily on clinical history and observed mental status. There are few reliable tests to assist or to confirm a diagnosis. Current knowledge is based on the best available data from clinical studies, epidemiological research, and careful observations of longitudinal course.


DEFINITION AND EPIDEMIOLOGY


Currently, depressive illnesses are classified into three broad categories: depressive disorders, dysthymic disorder, and bipolar affective disorder or cyclothymic disorder (see Table 93-1). Estimates of the point prevalence of major depression are approximately 1.5% to 2.5% in prepubertal children, increasing to 3% to 8% during adolescence. Bipolar affective illness is estimated at a point prevalence of 0.2% to 0.4% among prepubertal children, increasing to approximately 1% among adolescents. Depressive illnesses do not show gender differences in prepubertal children; however, at puberty, there is a significant increase in major depression among females, resulting in a female-to-male ratio of 3:1 during adolescence. Some research suggests that early onset of puberty increases the risk of depression in girls.1 Bipolar disorders are equally common in males and females throughout the life cycle.


Anxiety disorders, attention deficit hyperactivity disorder (ADHD), substance abuse, and conduct disorder can be concurrent with mood disorders. Some may show more genetic transmission (eg, ADHD). However, other comorbid states may represent bidirectional causality. Evidence from one longitudinal study suggests that anxiety disorders often antedate depressive symptomatology, whereas conduct symptoms generally follow an affective illness.2


ETIOLOGY AND PATHOGENESIS


Most etiologic models of early onset depression focus on the interactions between individual vulnerabilities and adverse life events. The central question of why some children grow up amidst chronic adverse conditions with no signs of significant mood disturbances, while others develop severe affective illnesses following relatively mild difficulties remains unanswered. Emotional trauma (eg, from physical and sexual abuse, loss of a parent, loss of a sibling or close friend) has been associated with the early onset of depressive disorders. Increased risk for early onset depression is associated with greater familial loading for depression, having a parent who developed depression at an early age (highly relevant to the recognition of postpartum depression), family history of either bipolar affective illness or recurrent unipolar depression, and major affective illness present in three generations. However, the single most important risk factor associated with developing an early depressive illness is having at least one depressed parent, with quadruple the risk for those with two depressed parents. Parental depression contributes to illness in the children through both genetic and shared environmental sources of transmission, including disruption of the parental role, decreased family support, and increased parent–child discord. Parent–child discord was shown to be significantly worse in families of depressed children when compared with those of nondepressed children in a control group. Additionally, emerging data suggest that toddlers and infants are at increased psychiatric risk secondary to relatively higher exposures to noxious and stressful stimuli such as abuse or neglect.3


Twin studies and familial patterns of depression strongly support the arguments for a genetic basis of depression. Concordance rates for depression are greater than 2:1 in monozygotic versus dizygotic pairs. A longitudinal study in New Zealand demonstrated that the interplay of life stress and a single allele difference in the serotonin transporter gene results in the development of depression in susceptible individuals but these conclusions are now being questioned.4


Child and adolescent depression has been associated with the use of medications such as glucocorticoids, immunosuppressives, antiacne treatments, antimalarials, and antivirals. Chronic illnesses such as cancer, cystic fibrosis, epilepsy, juvenile diabetes, sickle cell anemia, and organ transplantation may also predispose the child and adolescent to developing an adjustment or mood disorder.


The relationship between mood disorders and neuroendocrine changes in children and adolescents is still not clear. It may be that abnormalities in the hypothalamic-pituitary axis (HPT; demonstrated by dexamethasone-suppression test) and blunted response to growth hormone (GH) increase the risk for depressive disorders. Some of these abnormalities have been found in nondepressed children who have very high rates of affective illnesses on both sides of the family, suggesting that these changes may represent a vulnerability trait for major depressive disorder.5


Functional neuroimaging in children and adolescents is still in its infancy, and the risk of exposing children to radiation limits further study. However, early studies corroborate results found in similar studies of adults: depressed subjects have a smaller prefrontal cortex and basal ganglia. This preliminary work suggests structural differences may be genetically transmitted and, like neuroendocrine changes, serve as trait marker for depression.6


CLINICAL MANIFESTATIONS


Depressed mood in children and adolescents can present as sadness, irritability, or boredom. Depressed children also are likely to have somatic complaints (eg, abdominal pain, headaches). A small number of very ill children present with psychotic features related to their mood disorder (ie, delusions of worthlessness, hopelessness, sin, or guilt; self-deprecatory or auditory hallucinations; and paranoid ideation).


An episode of mania is usually characterized by euphoria or grandiosity (ie, an unrealistic sense of being grand, powerful, or famous) and indicates a bipolar affective disorder (BPAD). Such episodes can be associated with anger and irritability as well. Mania can be differentiated from attention deficit hyperactivity disorder, because mania is much more likely to present with increased energy, increased sexuality, euphoria, and grandiosity. Clinically, it can be quite difficult to diagnose mania or hypomania in very young children; however, in its most severe forms, children and adolescents with mania display bizarre behaviors and irrational ideas (such as the belief that they can fly) that are not present in other syndromes. Like adults, adolescents in manic episodes show periods of prolonged excitation, euphoria, rapid speech, grandiosity, sensation seeking, and promiscuity. When children and adolescents with bipolar disorder are depressed, they often present as anergic (ie, low energy and slow), hypersomnic, and psychotic.



Table 93-1. DSM-IV Criteria for Depression, Dysthymia, Mania, and Mixed Mood State








































DSM-IV Criteria for Major Depressive Disorder


1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.



Note: Do note include symptoms that are clearly due to a general medical condition or mood-incongruent delusions or hallucinations.


a. Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad or empty) or observation made by others (eg, appears tearful). Note: In children and adolescents, can be irritable mood.


b. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or by observation made by others)


c. Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.


d. Insomnia or hypersomnia nearly every day


e. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)


f. Fatigue or loss of energy nearly every day


g. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)


h. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)


i. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide


2. The symptoms do not meet criteria for a mixed episode.


3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.


4. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, hypothyroidism).


5. The symptoms are not better accounted for by bereavement (ie, after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation).



DSM-IV Criteria for Dysthymia

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Jan 7, 2017 | Posted by in PEDIATRICS | Comments Off on . Affective Disorders and Suicide

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