Pediatric Mood Disorders

Document Sample
Pediatric Mood Disorders Powered By Docstoc
					Mood Disorders In Children With Epilepsy

           Shlomo Shinnar MD PhD
                      and
           Christine O’Dell RN MSN


      Comprehensive Epilepsy Management Center
    Montefiore Medical Center/Albert Einstein College of
                        Medicine
                    Bronx, New York
Mood Disorders In Children With Epilepsy


   Mood Disorder

       Mood - a conscious state of mind or predominant
        emotion; feeling; a prevailing attitude
       Disorder – an abnormal state of body or mind;
        ailment



           The   Merriam-Webster Dictionary
Mood Disorders In Children With Epilepsy

DSM IV– Diagnostic and Statistical Manual of
 Mental Disorders
  Diagnostic Criteria –
Major Affective Disorders
        Manic
        Major depressive episode
        Bipolar disorder
        Others -Cyclothymic disorder and dysthymic disorder
   Anxiety
   Psychosis
    Mood Disorders In Children With Epilepsy
    Incidence of Psychiatric and Behavioral Comorbidities


    Population-based, retrospective                                                                 Prevalence
                                                                                         25
     study
      Incident cases of epilepsy

        (1980-1995)                                                                      20
      Rochester, MN




                                                                        Prevalence (%)
                                                                                              17%
    Prevalence                                                                          15
      DSM-IV diagnosis: 51%
        (69/104)                                                                                        12%
      Without mental retardation
                                                                                         10                       10%
        and/or pervasive developmental
        disorder: 40.4% (44/109)                                                          5
    Children with newly diagnosed
     epilepsy frequently exhibit
     comorbid psychiatric or behavioral                                                   0
     disorders                                                                                ADHD     Mood    Adjustment
                                                                                                      Disorder  Disorder
    Hedderick E and Buchhalter JR. Comorbidity of childhood-onset
     epilepsy and psychiatric and behavioral disorders: a population-
     based study. Ann Neurol 2003;54(suppl 7):S115.
Mood Disorders In Children With Epilepsy
Behavior disorders in children with epilepsy


167 children with chronic seizures, no MR
   ADHD: inattentive 22.8%, combined 11.4%, hyperactive
    2.4%
   ODD 20.4%, CD 18%
   Mood 9.6%
   Anxiety disorders: about one-third




    Dunn, Austin, Epilepsy Foundation, 2005, Epilepsy and Cognition.
Mood Disorders In Children With Epilepsy



   12-26% of pediatric epilepsy patients have a
    mood disorder
   Children with mood or anxiety disorders or
    psychosis usually have trouble with
    concentration and attention
   Younger children who are depressed may be
    diagnosed with oppositional defiant disorder
Mood Disorders In Children With Epilepsy


   Depression in 4.1% of children

   Anxiety in 9.5% of children

   Depression - girls > boys

   Adolescents may present like adults
Mood Disorders In Children With Epilepsy
Depression


      Prevalence: 20-30%
      Differential diagnosis: medication effect,
       particularly phenobarbital and topiramate,
       possibly due to increase in GABA
      Association with left temporal lobe discharges
       in adults
      Association with external or unknown locus of
       control

Dunn DW, et al. Symptoms of depression in adolescents with epilepsy. J Am Acad Child Adolesc Psychiatry
1999;38(9):1132-1138.)
Mood Disorders In Children With Epilepsy
Anxiety


       Prevalence: 15-25%
       Differential diagnosis: panic disorder versus
        seizure
       More common in adolescents and those with
        poorly controlled seizures or on multiple
        AEDs



     Ettinger AB, et al. Epilepsia 1998;39(6):595-599; Alwash RH, et al. Seizure 2000;9(6):412-416; Oguz A, et al.
     J Child Neurol 2002;17(1):37-40.
Mood Disorders In Children With Epilepsy
Psychosis


   Prevalence: rare
   Types of psychosis
       Ictal
       Postictal
       Interictal
       Alternative or forced normalization
   Association of illogical thinking in children with
    complex partial seizures but not generalized
    seizures
                   Caplan R, et al. J Am Acad Child Adolesc Psychiatry. 1997;36:1286-1294.
Mood Disorders In Children With Epilepsy
Aggression


      Prevalence: limited information
      Occurs with restraint during postictal
       confusion and with postictal psychosis
      Association with underlying central nervous
       system damage
      Oppositional defiant disorder/conduct
       disorder 10 – 35%

      Schachter SC. 2001
Mood Disorders In Children With Epilepsy


Diagnostic Tools

    The Kiddie Schedule for Affective Disorders and
     Schizophrenia (K-SADS)

    The Children’s Depression Inventory

    The Child Behavior Checklist (CBCL)
Mood Disorders In Children With Epilepsy


Diagnostic Tools, Continued

     The Multidimensional Anxiety Scale for Children
      (MASC)

     The Revised Children’s Manifest Anxiety Scale
      (RCMAS)

     The State-Trait Anxiety Inventory for Children
      (STAI-C)
Mood Disorders In Children With Epilepsy
Epilepsy Comorbidity in Children and Adults

   Exact incidence of psychiatric/behavioral comorbidity is
    difficult to ascertain
   Comorbidity is frequent in epilepsy
   Condition may significantly affect epilepsy
   Epilepsy may affect comorbid condition
   Treatments impact comorbid conditions
   Optimal treatment should be designed to benefit both
   Quality of life is markedly influenced by epilepsy and
    comorbidity
Mood Disorders In Children With Epilepsy
Epilepsy and Neurological Comorbidity

     Approximately 30% of patients with epilepsy have
            significant neurological comorbidity
          MR, CP, autism, prior stroke, major head trauma,
           encephalitis
    Conversely epilepsy is more common in those with
     these neurological impairments or prior neurological
     insults
          MR, CP, autism, prior stroke, major head trauma
    Mood disorders are more common in children with
     epilepsy and neurological comorbidity but may
     present differently and require different therapeutic
     approaches
Mood Disorders In Children With Epilepsy



   Antiepileptic drugs and Mood Stabilizers
        Carbamazepine

        Valproic Acid

        Lamotrigine
Mood Disorders In Children With Epilepsy
Treatment of Depression in Epilepsy



   Define the depression in relation to seizures
    (prodromal, periictal, interictal)
   Optimize seizure control
   Review AEDs
   Access psychosocial issues
   Antidepressants


Epilepsy Foundation, 2005, Epilepsy and Cognition.
Mood Disorders In Children With Epilepsy
Treatment of Depression in Children with Epilepsy

    Serotonin reuptake inhibitors:
            fluoxetine (Prozac)
            sertraline (Zoloft)
            citalopram (Celexa, Lexapro)
            paroxetine (Paxil)
            fluvoxamine (Luvox)
    Tricyclic Antidepressants:
            amytriptyline (Elavil)
            nortriptyline (Pamelor)
    Others:
              venlafaxine (Effexor)
              bupropion (Wellbutrin) and Cognition


    Epilepsy Foundation, 2005, Epilepsy
Mood Disorders In Children With Epilepsy

Treatment of Anxiety in Children with Epilepsy



   Serotonin reuptake inhibitors
    1. fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa,
    Lexapro)
    2. Side effects are upset stomach, restlessness, and rarely self-injury
   Benzodiazepines
    1. clonazepam (Klonopin), etc.
    2. Side effects: hyperactivity, lethargy




     Epilepsy Foundation, 2005, Epilepsy and Cognition
Mood Disorders In Children With Epilepsy
Management of Psychosis




   Antipsychotics
        clozapine, chlorpromazine

        thioridazine, olanzapine, quetiapine

        haloperidol, risperidone
Mood Disorders In Children With Epilepsy
Psychotropic Medications and Epilepsy


 All somewhat lower seizure threshold
 Effect generally mild and rarely clinically significant

 Frequently needed due to co-morbidity

 In children with well controlled seizure disorders use of
  these drugs is unlikely to result in seizures
 In children with uncontrolled seizure disorders use of these
  drugs may slightly increase seizure frequency
HOWEVER: Morbidity of the co-morbid condition will frequently
  exceed the morbidity of the somewhat increased seizure
  frequency
Mood Disorders In Children With Epilepsy
    Psychotropic Medications and Epilepsy: Conclusions



   Be alert for potential drug interactions
       Primarily with enzyme inducing AEDs (PHT, CBZ, PB)
       Some drugs are enzyme inhibitors (VPA)
   PICK BEST PSYCHOTROPIC MEDICATION FOR THAT CHILD’S
    CONDITION
       Do not try and “kill two birds with one stone”
       Treat significant symptomatology even if results in a few more
        seizures
       As with all drugs - look at risk – benefit ratio
Mood Disorders In Children With Epilepsy


   Treatment –Psychological/Behavioral Therapy
     Psychotherapy and counseling

       coping, relaxation techniques



       Education - patient and family
         communication, epilepsy, psychiatric



       Behavior therapy/modification
         anger management

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:9/1/2012
language:English
pages:23