Psychiatric Issues

From Clinical Pediatrics, Southern California Pediatric Postgraduate Meeting 2010,
presented by the American Academy of Pediatrics, California Chapter 2

Stephen V. Sobel, MD, Clinical Instructor, University of California San Diego School of Medicine

Educational Objectives

The goal of this program is to improve management, at the primary care level, of anxiety and depressive disorders and bi­polar disorder (BPD) in children and adolescents. After hearing and assimilating this program, the clinician will be better able to:

1.   Explain the techniques of cognitive therapy.

2.   Use cognitive therapy as an effective alternative or possible adjunct to pharmacotherapy for the treatment of anxiety and depression.

3.   Effectively screen patients presenting with depressive symptoms for BPD.

4.   Recognize the relationship between BPD and comorbid conditions.

5.   Differentiate between BPD and attention deficit disorder.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Sobel is on the Speakers’ Bureaus for Bristol-Myers Squibb, Forest Laboratories, Pfizer, and Schering-Plough. The planning com­mittee reported nothing to disclose. In his lecture, Dr. Sobel presents information that is related to the off-label or investiga­tional use of a product, therapy, or device.  

Acknowledgments

Dr. Sobel spoke in Palm Springs, CA, at Southern California Pediatric Postgraduate Meeting, presented February 11-14, 2010, by the American Academy of Pediatrics, California Chapter 2. The Audio-Digest Foundation thanks Dr. Sobel and the American Academy of Pediatrics, California Chapter 2 for their cooperation in the production of this program.

Cognitive Therapy for Anxiety and Depression

Anxiety: to manage child or adolescent with anxiety or depression, educate patient and parents; identify and address en­vironmental factors and possible stressors; consider general medical factors; perform physical examination; treatment options include psychotherapy and/or pharmacotherapy; psychotherapy in form of relaxation, exposure therapy, or cognitive behavioral therapy; pediatricians routinely and effectively deal with child’s and parents’ emotions regarding diagnoses and required therapy

Concepts: event occurs and produces specific thought; leads to specific feeling (ie, “mad, sad, glad, or scared”), then to response to feeling (eg, avoidance of situation); assumptions  —learned at young age (usually from parents); classifica­tion of cognitions  —  automatic or planned; positive or negative; accurate or distorted; functional or dysfunctional; pa­tients of all ages with anxiety tend to have automatic, negative, distorted, and/or dysfunctional thoughts; individuals assume thoughts true and accurate, even when not

Cognitive model of depression and anxiety: anxious patient  —tends to devalue coping ability; exaggerates danger; at­tends selectively to dangerous stimuli; has difficulty appraising information accurately; makes cognitive errors; cognitive therapy  —  involves identification, challenge, and correction of automatic negative distorted and dysfunctional thoughts; targets maladaptive thoughts, feelings, and behaviors, and helps patients learn alternatives to their way of thinking; com­patible with biopsychosocial etiology; proposed mechanism of action  —  serotonin required to interrupt negative thought loop; uncontrolled negative thought loops  —  about fear of infectious disease may result in obsessive-compulsive disorder (eg, manifested by repetitive hand washing); about loss or success, may result in depression; about fear of devastating fu­ture events, may result in anxiety; about obesity, may result in anorexia or bulimia

Cognitive behavioral therapy (CBT): can be used as initial alternative to pharmacotherapy, as replacement strategy for pharmacotherapy, or in combination with medication; teaches patients to identify negative maladaptive thoughts and treat as hypotheses; monitor and evaluate accuracy of thoughts by seeking information that tests validity of hypothe­ses; results in eventual substitution of more accurate and functional thoughts; exposure interventions  —  establish hier­archy of fearful situations or objects; begin with least threatening and work up to most threatening; avoid use of benzodiazepines to increase therapeutic impact of exposure (patient may attribute success to medication )

Studies of efficacy: Sequential Treatment Alternatives for Remission in Depression (STAR-D)  —  per speaker, most important study in psychiatry in last decade; 3671 participants (mostly adults; some adolescents); no exclusions for comorbidities; all placed on citalopram (Celexa) for treatment of major depression, and followed for 12 weeks; only looked at outcome of remission (achieved in 33%); switched to a variety of other therapies including augmentative treatments and CBT; CBT had success rate similar to all other therapies (good level of efficacy); Treatment for Adolescents with Depression Study (TADS)  —  439 participants followed for 12 weeks; to date, larg­est study of adolescent depression; compared responses to fluoxetine (eg, Prozac, Sarafem) alone to those with CBT alone, combination therapy (fluoxetine and CBT), and placebo; with addition of CBT, response increased from 61% to 71%, and rate of remission increased from 23% to 37%; conclusion  —  addition of CBT gives more robust outcome

Advantages: CBT 70% to 85% effective; lower relapse rate than medication when discontinued; good patient ac­ceptance; time-limited; overall cost low; few (if any) adverse effects

Disadvantages: more difficult to administer than medication; limited availability; requires more effort than taking medication; third-party coverage often unavailable; not possible for all patients (eg, those with high anxiety, se­vere illness, cognitive impairment)

Treatment process: 1) identify automatic negative thought (ANT); 2) identify event that triggered ANT and feelings and responses associated with that event; 3) estimate (by percentage) degree of accuracy of ANT; 4) identify types of distortion present; 5) identify solid evidence supporting ANT; 6) identify solid evidence against ANT; 7) weigh evidence (determine whether supporting or refuting evidence stronger); 8) revise accuracy estimate of ANT; 9) identify realistic restatement based on evidence (eg, revise “I cannot succeed in school” to “I can probably succeed in school”); 10) identify new feelings and response; 11) determine how ANT developed; 12) determine what learned from this experience

Cognitive distortions: polarized thinking  —  either perfection or failure; mental filtering  —  focus on negative while filter­ing out all positive aspects; overgeneralization  —  negative conclusion based on single piece of information generalized to all situations; mind-reading  —  individual believes he or she knows other people’s thoughts or opinions; catastrophizing  —  expecting disaster; personalization  —individual believes that everything that happens relates to him or her; blaming  —  holding others responsible for pain, or blaming self for everything; emotional reasoning  —believing that whatever individual feels must be true; global labeling  —take one or 2 qualities and generalize into negative global assessment; heaven’s reward fallacy  — expecting sacrifice to pay off (as if score being kept); fallacy of change  — expecting that other people will change to suit patient (if sufficiently pressured, pleased, or cajoled); fortune-telling  —  believing that one can predict future and that one’s behavior’s will affect future in predictable manner; disqualifying the positive  —  rejecting anything positive that does not support negative thought; minimalization  —  shrinking one’s own positive qualities

Desired outcomes: ANTs replaced with accurate thoughts; patient recognizes that psychiatric symptoms always due to combination of biologic, psychologic, and environmental factors

Recognizing Bipolar Disorder (BPD) in Adolescence

Screening: every adolescent with depressed mood, anxiety, behavioral disruptions, history of drug or alcohol abuse; Food and Drug Administration (FDA) advises screening for BPD before initiating antidepressant treatment

Depression: presentation different in children than in adults; symptoms  —  sad or irritable mood; loss of interest in ac­tivities once enjoyed (may need to infer from behavior); moves or speaks slowly; cries excessively for age; self-esteem plummets; talk of death or suicide; major depression  —  diagnosis of exclusion; 10% to 60% of adoles­cents who present with depression eventually diagnosed with BPD; BPD in adolescents usually presents in de­pressed or mixed phase (rarely in manic phase); depression can also have organic cause, relate to substance abuse, or be response to life event

Study data: long-term frequency of phases in adults with BPD  —  asymptomatic »50% of time; during symptomatic periods, two-thirds of time spent in depressed phase; depression most common presentation of BPD disorder, and therefore often treated with antidepressants (can aggravate BPD); time to diagnosis  —  study of 600 adults with BPD; correct diagnosis required 4 visits to different mental health professionals over 8.5 yr-period; if symptoms began in childhood or adolescence, 15 yr required; BPD typically misdiagnosed as depression (60%), schizo­phrenia (20%), anxiety (20%), or antisocial or borderline personality disorder (20%)

Making proper diagnoses in adolescents: behavior (along with history and information from parents) key

Reason for underrecognition: possible presenting symptoms  —depression; anxiety; insomnia; irritability; low energy and fatigue; inability to focus; drug or alcohol abuse; trouble in school or with law; relationship problems; im­pulse control problems; no complaints; variability in presentation makes diagnosis difficult

BPD in youth: common disorder (»1 million adolescents in United States); impairment can be severe; treatment can be difficult; families fear stigma; earlier onset often predicts more adverse course; treatment initiation frequently delayed (average 15 yr); incidence increasing; age at onset decreasing (child of parent with BPD has 25%-60% chance of developing disorder; child typically 10 yr younger than parent at age of diagnosis); clear definitive diag­nostic criteria lacking; misdiagnosed as attention deficit-hyperactivity disorder (ADHD); insurance companies his­torically biased against reimbursement; treatment often inadequate or inappropriate

Assessment: ask about history of mania and hypomania; ask about family history of BPD; involve family mem­bers in evaluation process; 2-appointment evaluation  —recommended because family generally unable to answer all questions at first visit without knowledge about BPD; after doing internet research, family much more capable of provid­ing aid in ruling out or ruling in diagnosis; administer screening instrument

Mood Disorder Questionnaire (MDQ): available on line; patient answers “yes” or “no” to series of symptomatic questions; eg, has patient experienced period of feeling unlike usual self (while not using drugs or alcohol)?; did this cause problems in various areas of life?; is there family history of mood disorders?; has health care profes­sional diagnosed patient with manic depression or BPD?; questionnaire saves time, but does not substitute for full evaluation

Mania in adults: elevated or euphoric mood, expansiveness, or irritability (latter is frequent presentation for adoles­cents); inflated self-esteem and grandiosity; decreased need for sleep while maintaining good or high energy; overly talkative, with “flight of ideas” (bouncing quickly between connected topics); distractibility; agitation and anxiety; excessive involvement in impulsive high-risk pleasurable activities

Hypomania: criteria from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) require duration of symptoms (eg, irritability) for 4 days; in adolescents, more common to see duration of 1 to 3 days, or even several hours (ultra-rapid cycling); associated depressive episodes characterized as hypersomnic, retarded, and nonagitated

Mania in children and adolescents: severe mood swings; overly irritable, silly, or elated; increased self-esteem; talking too fast and changing topics quickly; easily distracted; excessively energetic with decreased need for sleep; aggressive, impulsive, and/or destructive behaviors; hypersexuality

Symptoms of hypomania or mania: useful mnemonic (DIGFAST); distractibility; insomnia; grandiosity; flight of ideas; activities (increased); speech (pressured); thoughtlessness

Differential diagnosis for BPD vs major depression: family history  —  higher rates of BPD (and psychiatric illness in general) if positive for BPD; course of illness  —  BPD usually begins in adolescence (one-third of patients have first episode before puberty), whereas major depression uncommon before »21 yr of age; duration of episodes  —  ranges from hours to days or weeks in BPD (major depressive episodes last months or years); frequency of episodes  —  1 to 4 episodes per year in major depression; 1 to 3 episodes per day, several per year in BPD; seasonality  —  BPD worse in winter; post-partum psychosis  —  BPD; treatment response  —  patients with BPD nonresponsive or have er­ratic response to antidepressants; mania  —  in adolescents, generally seen only in mixed phase with depression; associ­ated features  —  unevenness in peer and family relationships; frequent career changes in adults (unevenness in school performance in adolescents); substance abuse

Comorbidities: rule rather than exception; many (including ADD) increased with BPD

Differentiating ADD from BPD: sleep  —  ADD patients have difficulty falling asleep, but do not usually exhibit excessive energy despite lack of sleep; grandiosity  —  not present in ADD; fluctuation of moods  —  ADD relatively consistent; family history  —  if one or both parents have ADD, child probably has same diagnosis; hypersexuality  —  in BPD, comes and goes with manic episodes; cardinal symptom  —in ADD, difficulty maintaining concentration; in BPD, dif­ficulty with mood regulation

Comorbid substance abuse: high lifetime rates among those with BPD; due to self-medication or impulsivity and impaired decision-making; screen patients with BPD repeatedly for substances

Questions and answers: treatment of psychiatric illness by pediatricians  —  accurate diagnosis for BPD difficult, even for psychiatrists; antidepressants precipitate rapid cycling in BPD patients (demonstrated by studies); if pediatri­cian suspects BPD, best to avoid prescription of antidepressant; dealing with lag time after referral to pediatric psychiatrist  —  when BPD strongly suspected or confirmed by pediatrician, can try prescription of serotonin-2 dopa­mine-2 (S2D2) antagonist (second-generation antipsychotic; first-line treatment for adults); lamotrigine (Lamictal) contraindicated in children; speaker recommends aripiprazole (Abilify) or ziprasidone (eg, Geodon, Zeldox); lithium or divalproex (eg, Depakote) also options; start with low dose; comorbid ADD and BPD  —  if primary symptoms re­lated to ADD, treat ADD first with stimulant other than atomoxetine (Stattera); if convinced that patient has both dis­orders, treat mood disorder first and then add stimulant

Suggested Reading

Altshuler LL et al: Impact of antidepressant continuation after acute positive or partial treatment response for bipolar depression: a blinded, randomized study. J Clin Psychiatry 70:450, 2009; Brotman MA et al: Amygdala activation during emotion processing of neutral faces in children with severe mood dysregulation versus ADHD or bipolar disorder. Am J Psychiatry 167:61, 2010; Chang KD: Course and impact of bipolar disorder in young patients. J Clin Psychiatry 71:e05, 2010; Chang KD: Diagnosing bipolar disor­der in children and adolescents. J Clin Psychiatry 70:e41, 2009; Chang K et al: Atomoxetine as an adjunct therapy in the treatment of co-morbid attention-deficit/hyperactivity disorder in children and adolescents with bipolar I or II disorder. J Child Adolesc Psycho­pharmacol 19:547, 2009; Findling RL et al: Acute treatment of pediatric bipolar I disorder, manic or mixed episode, with aripipra­zole: a randomized, double-blind, placebo-controlled study. J Clin Psychiatry 70:1441, 2009; Hlastala SA et al: Interpersonal and social rhythm therapy for adolescents with bipolar disorder: treatment development and results from an open trial. Depress Anxiety 27:epub, 2010; Leverich GS et al: The poor prognosis of childhood-onset bipolar disorder. J Pediatr 150:485, 2007; Parisi P: Mi­graine and suicidal ideation in adolescents aged 13 to 15 years. Neurology 73: 1713, 2009; Post RM et al: Incidence of childhood-on­set bipolar illness in the USA and Europe. Br J Psychiatry 192:150, 2008; Potter MP et al: Prescribing patterns for treatment of pediatric bipolar disorder in a specialty clinic. J Child Adolesc Psychopharmacol 19:529, 2009; Sparhawk R: Antidepressants in bi­polar disorder: caveats in interpreting and applying the findings of Altshuler et al. J Clin Psychiatry 71:211, 2010; Wozniak J et al: A controlled family study of children with DSM-IV bipolar-I disorder and psychiatric co-morbidity. Psychol Med 6:1, 2009; Zeni CP et al: Methylphenidate combined with aripiprazole in children and adolescents with bipolar disorder and attention-deficit/hyperactivity disorder: a randomized crossover trial. J Child Adolesc Psychopharmacol 19:553, 2009.