Mood Disorders

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Chapter 24 Mood Disorders

The mood disorders have a disturbance in mood as the predominant feature, and are divided into the depressive disorders, in which the mood is depressed or irritable, and the bipolar disorders, in which the mood is elevated, expansive, or irritable. These mood disturbances exist on a dimensional spectrum ranging from sub-syndromal (i.e., some symptoms are present, but not enough to meet full diagnostic criteria) to syndromal (i.e., full diagnostic criteria are met). The syndromal disorders are themselves dimensional, ranging in severity from mild to severe.

24.1 Major Depression

Description

In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), major depressive disorder is characterized by a distinct period of at least 2 wk (an episode, Table 24-1) in which there is a depressed or irritable mood that is present for most of the day nearly every day, and/or loss of interest or pleasure in nearly all activities. There also are associated vegetative and cognitive symptoms, including disturbances in appetite, sleep, and energy; impaired concentration; and thoughts of worthlessness, guilt, and suicide. To meet the syndromal diagnosis, 5 or more symptoms (including depressed or irritable mood or loss of interest or pleasure) must be present and must represent a distinct change from previous functioning, cause clinically significant distress or impairment, not be better accounted for by bereavement or by other psychiatric disorders, and not be due to the direct physiologic effects of a substance or a general medical condition.

Table 24-1 DSM-IV-TR DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE EPISODE

A 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.

From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fourth edition, text revision, Washington, DC, 2000, American Psychiatric Association.

Major depressive disorder is categorized as mild if few symptoms in excess of those required to make the diagnosis are present and the symptoms result in only minor functional impairment, and it is categorized as severe if several symptoms in excess of those required are present and the symptoms markedly interfere with functioning. Severe major depression is subcategorized as occurring with or without psychotic features (hallucinations or delusions). Moderate major depression is intermediate between mild and severe.

Overall, the clinical presentation of major depressive disorder in children and adolescents is similar to that in adults. The prominence of the symptoms can change with age; somatic complaints, irritability, and social withdrawal may be more common in children (who are less able to verbalize their feeling states), and psychotic and melancholic symptoms or suicidal behavior may be more common in adolescents.

Differential Diagnosis

A number of psychiatric disorders, general medical conditions, and medications can generate symptoms of depression and irritability and must be distinguished from the depressive disorders. The psychiatric disorders include anxiety (Chapter 23), attention-deficit/hyperactivity disorder (ADHD) (Chapter 30), disruptive behavior (Chapter 27), developmental disorders (Chapter 28), substance abuse (Chapter 108), and adjustment disorders. Medical conditions include neurologic disorders, endocrine disorders, infectious diseases, tumors, anemia, uremia, failure to thrive, chronic fatigue disorder, and pain disorder. Medications include narcotics, chemotherapy agents, cardiovascular medications, corticosteroids, and contraceptives. The diagnosis of a depressive disorder should be made after these other explanations for the observed symptoms have been ruled out.

Comorbidity

Major depressive and dysthymic disorders (Chapter 24.3) often co-occur with other psychiatric disorders, and both can occur concurrently (double depression). Depending on the setting and source of referral, 40-90% of youths with a depressive disorder have other psychiatric disorders, and up to 50% have 2 or more comorbid diagnoses. The most common comorbid diagnosis is an anxiety disorder, followed by disruptive behavior, ADHD, and substance use disorder.

Sequelae

Approximately 60% of youths with major depression report thinking about suicide, and 30% actually attempt suicide (Chapter 25). The risk of suicidal behavior increases if there is a history of suicide attempts, exposure to adverse psychosocial circumstances, a family history of suicidal behavior, or comorbid psychiatric disorders. Youths with depressive disorders are also at high risk of substance abuse, impaired academic performance, impaired family and peer relationships, and poor adjustment to life stressors, including physical illness.

Early Identification

Clinicians should screen all children and adolescents for the key depressive symptoms of sad mood, irritability, and anhedonia (Table 24-2). A diagnosis of a depressive disorder should be considered if these symptoms are present most of the time, affect the child’s functioning, and are beyond what would be expected for the given circumstances. The use of standardized depression rating scales (Chapter 18) designed for self- or parent report can be helpful in the screening process. If the screening indicates clinically significant depressive symptoms, the clinician should refer to a specialist for a comprehensive diagnostic evaluation to determine the presence of depressive and other comorbid psychiatric and medical disorders. The evaluation must include assessment of the potential for harm to self or others.

Table 24-2 SCREENING AND TREATMENT FOR MAJOR DEPRESSIVE DISORDER IN YOUTHS

RECOMMENDATION ADOLESCENTS (12-18 YR) CHILDREN 7-11 YR)
Screening

Risk assessment Risk factors for major depressive disorder include parental depression, having comorbid mental health or chronic medical conditions, and having experience a major negative life event Screening tests Screening instruments perform less well in younger children Treatments Among pharmacotherapies, fluoxetine, a selective serotonin reuptake inhibitor (SSRI) has been found efficacious. However, because of risk of sucidality, SSRIs should be considered only if clinical monitoring is possible. Various modes of psychotherapy, and pharmacotherapy combined with psychotherapy, have been found efficacious. Evidence on the balance of benefits and harms of treatment of younger children is insufficient for a recommendation

For a summary of the evidence systematically reviewed in making these recommendations, the full recommendation statement, and supporting documents, please go to www.AHRQ.gov/clinic/USPSTF/USPSCHDEPR.htm

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