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Elizabeth B. Weller, Roomana M. Sheikh, Seth D. Laracy, Ronald A. Weller: Chapter 1. Mood Disorders and Suicidal
Behavior, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009
American Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.250000. Printed 5/10/2009 from
www.psychiatryonline.com
Gabbard’s Treatments of Psychiatric Disorders > Part I. Disorders Usually First Diagnosed in Infancy, Childhood, or
Adolescence >
Chapter 1. Mood Disorders and Suicidal Behavior
INTRODUCTION
Treatment of mood disorders and suicidal behavior is complex. It requires knowledge of the proper
diagnostic assessment of the disorders and familiarity with the changing concepts and evolving
treatment strategies for these conditions. Accurate diagnosis is the key to successful treatment and
requires a comprehensive psychiatric diagnostic evaluation, which includes interviews with the
child, parents, and collateral informants (e.g., teachers, social services personnel). The psychiatric
assessment of depressed and manic children and adolescents is difficult and must be performed by
a clinician who pays attention to developmental, environmental, and cultural factors that may affect
the patient’s clinical presentation.
TREATMENT OF DEPRESSIVE DISORDERS
The treatment of depression in children and adolescents is going through a major revision of
prescribing practices for antidepressants, particularly selective serotonin reuptake inhibitors
(SSRIs). Since their introduction in the 1980s, SSRIs have been tested extensively in adults. They
are considered safe and effective for adults and represent an improvement over older
antidepressant medications because of their fewer side effects and relative safety if taken in an
overdose.
Although much less studied in children and adolescents, their use increased for many years until
recently. From 1996 to 1997, children between the ages of 6 and 18 years received 792,000
prescriptions for SSRIs to treat depression. During this same period, the number of children ages 5
years and younger taking these medications jumped 500%, from 8,000 to 40,000 (Hoar 1998). In
subsequent years, patients younger than 18 years received 1,664,000 prescriptions for fluoxetine,
sertraline, paroxetine, and fluvoxamine. This widespread use of SSRIs for pediatric depression was
based on six positive published studies. Fluoxetine has the most convincing evidence of efficacy,
with three positive clinical trials. More modest evidence is available for sertraline, paroxetine, and
citalopram. Experts believe that this widespread use of SSRIs is a pivotal factor in the recent
decrease in suicide rates in adolescents.
Recently, the benefits of SSRIs have been questioned in both the United Kingdom and the United
States. In June 1993, the Medicines and Healthcare Products Regulatory Agency (MHRA) (the U.K.
equivalent of the U.S. Food and Drug Administration [FDA]) and the FDA suggested that SSRIs
might increase suicidality in children and adolescents. In December 2003, the MHRA declared that
all antidepressants except fluoxetine were contraindicated in pediatric depression. In the U.S., the
FDA required that all antidepressants be labeled with a warning about their potential for inducing
suicidal thoughts or behavior in children and adolescents. The FDA also recommended that patients
and parents be better informed regarding antidepressant treatment but stopped short of
recommending contraindications for these drugs. The FDA’s recommendation was based on 24
placebo-controlled studies of nine antidepressants that included more than 4,400 patients. Of the
2,200 patients who received SSRIs in these studies, none completed suicide. However, the rate of
suicidal thinking or behavior (including actual suicidal attempts) was 4% for patients receiving
SSRIs and 2% for those receiving placebo. The FDA regarded the risk as small but real.
It is very difficult to determine whether SSRIs increase the risk of completed suicide, given that
depression itself increases the risk for suicide and that completed suicide is a rare event. ControlledPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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trials typically include hundreds of patients, not the thousands needed to detect rare events. In
addition, controlled clinical trials typically exclude patients at high risk for suicide. In addition,
some believe that treatment with antidepressants is more likely to unmask bipolar disorder in
children or adolescents than in adults, which can result in a mixed manic and depressive state—a
condition that carries a very high risk of suicidal behavior. These concerns raise the question of
whether SSRIs should be given to children at all. Giving SSRIs to adolescents might increase
suicidality, but curtailing the use of SSRIs runs the risk of turning the clock back to the 1980s,
when suicide rates were rising.
Unfortunately, psychosocial treatment alone may not be adequate to help all depressed children
and adolescents, especially those with moderate to severe depression. Although
cognitive-behavioral therapy (CBT) appears to be more effective than other psychosocial
treatments for depression, the one study that directly compared CBT with medication treatment in
depressed adolescents found that it was inferior to fluoxetine therapy and no better than placebo
(March et al. 2004). With medication, the risk–benefit ratio is better for fluoxetine than for other
antidepressants, but nearly 40% of depressed adolescents do not respond to it and others cannot
tolerate it. Other antidepressants with evidence of safety and efficacy should be considered for
these patients. A balance between the need for effective antidepressant treatment and the need to
minimize adverse effects (including suicidal behavior) needs to be found.
General Principles
Treatment of depression is usually broken down into three phases: 1) acute treatment, which
brings the patient into treatment and lasts until symptoms remit; 2) continuation treatment, which
lasts an additional 6–12 months to ensure continuation of remission; and 3) the maintenance
phase, during which the clinician decides whether ongoing treatment is still necessary to prevent
relapse or recurrence.
In the acute phase, depressed youth should be treated in the least restrictive setting that is safe
and effective for a given patient. Selection of treatment setting (e.g., outpatient, partial
hospitalization or day treatment, inpatient, or residential) depends on the availability of a safe
environment, severity of the illness, motivation of the patient and/or the patient’s family for
treatment, and severity of comorbid psychiatric (e.g., substance abuse) or medical conditions. The
choice of initial intervention(s) depends in part on the treatment setting. Other factors include the
number of prior episodes, chronicity, subtype of depression (e.g., psychotic, bipolar, or atypical),
patient age, contextual issues (e.g., family conflict, academic problems), and the availability and
expertise of the clinician. The decision to initiate medication and/or psychotherapy should be made
jointly by the clinician and adequately informed parents/guardians with the assent of the child.
Specific therapies (e.g., CBT, interpersonal therapy) may be as effective as medications in mild to
moderate depression (Brent et al. 1997). In many cases, therapy is an important addition to
pharmacotherapy to help deal with psychosocial and academic consequences of depression.
Antidepressant medications may be indicated for children and adolescents with non-rapid-cycling
bipolar or psychotic depression who have 1) severe symptoms that prevent effective involvement in
psychotherapy, 2) symptoms that fail to respond to an adequate trial of psychotherapy, or 3)
chronic or recurrent depression. Specific target symptoms should be identified before
pharmacological treatment is started. Patients and parents should be informed about side effects,
dose schedule, time course for onset of therapeutic effect, and dangers of overdose. Parents should
accept responsibility for storing and administering medications to enhance compliance and
minimize the risk of overdose. Quantity of dispensed medications needs to be monitored carefully.
Practice parameters endorsed by the American Academy of Child and Adolescent Psychiatry
(AACAP) in 1998 recommend continuation therapy at the same dose for at least 6 months after
remission of acute symptoms. Psychotherapy can be used to help patients and families consolidate
the skills learned during the acute phase, cope with the psychosocial sequelae of the depression,
effectively address environmental stressors, and understand inner conflicts that may trigger aPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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relapse. The patient and family should be taught to recognize early signs of relapse. If the patient is
taking antidepressants, continuation psychotherapy can help foster medication compliance. At the
end of the continuation phase, patients determined not to require maintenance treatment can have
their medications discontinued slowly over a period of 6 weeks or longer to avoid side effects.
Maintenance therapy should be considered for patients with multiple or severe episodes of
depression or a high risk for recurrence. Those with a history of two or more episodes of depression
should receive maintenance treatment for at least 1–3 years. For patients with more than three
episodes or recurrent episodes accompanied by psychosis, severe impairment, severe suicidality, or
treatment resistance, longer treatment should be considered. Factors associated with recurrence
include a family history of bipolar disorder or recurrent depression, comorbid psychiatric disorders,
stressful or nonsupportive environments, and residual or subsyndromal symptomatology.
Treatments used to induce remission in the acute phase should be used for maintenance therapy.
Treatment-resistant depression is a serious problem. Potential reasons for treatment failure include
inaccurate diagnosis, inadequate antidepressant dosage, inadequate length of antidepressant
treatment, inadequate length of psychotherapy, inadequate fit with and/or skill level of
psychotherapist, lack of compliance with treatment, comorbidity with other psychiatric disorders,
comorbid medical illness, bipolar depression, and exposure to chronic or severe life events (e.g.,
sexual abuse) that may require different modalities of therapy. Several psychopharmacological
strategies have been recommended for adults: 1) optimization (extending the initial medication
trial and/or adjusting the dose), 2) switching to a different class of medication, 3) augmentation or
combination treatment (e.g., lithium, triiodothyronine [T3]), and 4) electroconvulsive therapy
(ECT). However, evidence-based efficacy of these strategies has not yet been demonstrated in
children and adolescents. Currently, the National Institute of Mental Health (NIMH) is funding a
study in 400 12- to 18-year-olds with treatment-resistant depression (Treatment Of Resistant
Depression In Adolescents [TORDIA; see http://www.wpic.pitt.edu/research/tordia and
http://www.clinicaltrials.gov/show/NCT00018902]) to determine the best treatment for patients
whose depression is “resistant” to the first SSRI tried.
Treatment Modalities
Psychotherapeutic Interventions
A trial of psychosocial therapy is indicated as the first line of treatment when 1) the patient and/or
family prefers psychosocial treatment, 2) the patient has contraindications to medication (e.g.,
pregnancy), 3) the patient has complex life stressors, or 4) the patient has failed to respond to
medication (Asarnow et al. 1999).
Depression can affect how a person thinks, relates, and views the world. Considerable evidence
indicates some level of disability may remain after the depression remits (e.g., Klein et al. 1997)
and supports the hypothesis that depressive episodes are associated with “psychosocial scars,”
difficulties that are present after but not before the episode. Psychosocial treatment strategies can
also be developed to specifically address any comorbid disorders or psychosocial stressors.
The psychosocial treatments tested to date with depressed youths have shown efficacy relative to
control conditions and/or comparison interventions. However, about 40% of the samples fail to
show significant recovery or remission as defined in each study. This rate is consistent with the rate
observed in pharmacological trials (Emslie et al. 1997). This is of relevance in prevention programs
where interventions designed to appeal to participants and introduced by enthusiastic research
teams could lead to reduction in depression, at least in the short term.
Systems-level interventions need to be considered in some cases when psychotherapy and/or
medication is insufficient. Wraparound services, residential treatment, and partial or full
hospitalization are needed for some youth and should be considered when safety or severity of
dysfunction dictates the need for more intensive services. The need for ancillary educational
services (e.g., tutoring, special education) as well as recreational (e.g., sports activities, clubs,
scouts) and/or social service (e.g., housing, food, job training) interventions that are likely to bePrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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helpful to the youth and family should be considered. Before selecting an intervention strategy, it is
useful to examine how the child and key family members view the patient’s difficulties and what
their expectations and beliefs are regarding various treatment alternatives.
Choice of Psychosocial Intervention
Various psychosocial treatment strategies have been used to treat depression in youth. Age at
onset of depression, severity of depression, presence of comorbid psychiatric disorders, lack of
support, parental psychopathology, family conflict, exposure to stressful life events, socioeconomic
status, quality of treatment, and motivation of both patient and therapist predict response to
psychotherapy. Additionally, comorbid anxiety and dysthymia, which predict poor response and
may persist after an episode of major depressive disorder (MDD), should also be a target of
psychosocial treatment.
Cognitive-Behavioral Therapy
CBT is based on the premise that depressed patients have cognitive distortions in how they view
themselves, the world, and the future that contribute to their depression. CBT teaches patients to
identify and counteract these distortions. Clinical studies of CBT report a high rate of relapse at
follow-up, suggesting a need for continuation treatment. Accumulating data support the efficacy of
both individual and group CBT for the treatment of depression in adolescents and, to a lesser
extent, in children.
The NIMH multisite Treatment for Adolescents with Depression Study (TADS; March et al. 2004)
compared fluoxetine with CBT, a combination of CBT and fluoxetine, and placebo. CBT alone was
not better than placebo, and both were inferior to fluoxetine alone. This is the only randomized
controlled trial to compare the efficacy of psychological and medication treatments for depression
in children and adolescents. More studies of this design are needed.
Two earlier independent studies (Clarke et al. 1999; Lewinsohn et al. (1990) reported a significant
advantage for group CBT for major depression or dysthymic disorder in adolescents compared with
a wait-list control condition. Results across the two studies showed a recovery rate of about 60.8%
at the end of CBT treatment.
Brent et al. (1997) examined the relative efficacy of 12–16 sessions of individual CBT, systemic
behavioral family therapy, and individual nondirective supportive therapy. A higher rate of
remission (60%) was found among adolescents who received CBT compared with those who
received either family therapy (29%) or supportive therapy (36.4%).
Wood et al. (1996) compared six to eight sessions of individual CBT for depression with relaxation
training in youth who met DSM-III-R (American Psychiatric Association 1987) criteria for major
depression or Research Diagnostic Criteria (Spitzer et al. 1978) for minor depression. There was a
significantly higher remission rate for youth in CBT treatment (54%) compared with those in the
relaxation treatment (21%).
Vostanis et al. (1996) reported substantial recovery (87%) following brief group CBT (two to nine
sessions; mean of six sessions) among 8- to 17-year-olds with major depression, dysthymic
disorder, or minor depression. Improvement was generally maintained at 9 month follow-up. High
recovery rates also were observed among youths in a comparison group on a nonfocused
intervention (75% recovery rate). The authors suggested that the nonfocused intervention group
had either a somewhat weaker psychotherapy effect or a high placebo response rate. It is
important to note, however, that this study included many youth with mild depression (54.4% with
minor depression) who may be more likely to respond to nonspecific therapy.
Rosello and Bernal (1999) reported that both CBT and interpersonal psychotherapy (IPT) led to
significant reductions in depressive symptoms compared with a wait-list control group in a sample
of Puerto Rican adolescents with major depression and/or dysthymic disorder.
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(i.e., booster sessions every 4 months) was associated with accelerated recovery among those who
were still depressed at the end of acute treatment. However, continuation treatment was not
associated with a decrease in recurrence rate.
Interpersonal Therapy
IPT focuses on the problem areas of grief, interpersonal roles, disputes, role transitions, and
personal difficulties. IPT has been useful in the acute treatment of adolescents with MDD. Relapse
rate may be relatively low after acute IPT treatment. IPT is based on the assumptions that
depression evolves in a social context, and as a result, the onset, response to treatment, and
outcome of depressive episodes are influenced by interpersonal relationships with significant
others. Major goals are to decrease depressive symptoms and to improve interpersonal functioning
by enhancing communication skills in major interpersonal relationships.
Data from two recent trials support the efficacy of IPT for depressed adolescents. First, Mufson et
- (1999) reported that IPT was associated with greater improvements in depressive symptoms,
social functioning, and problem-solving skills in adolescents with major depression compared with
a clinical monitoring control group. Second, Rosello and Bernal (1999) reported a significant
advantage for IPT, compared with a wait-list condition, among Puerto Rican adolescents with major
depression and/or dysthymic disorder. Youths who received IPT showed greater gains in social
functioning and self-esteem when compared with the wait-list group. These two studies underscore
the promise of IPT for adolescent depression. However, both of the completed studies evaluating
IPT in adolescents included largely Latino samples. Similar studies are needed to confirm IPT’s
efficacy in other cultural groups.
A treatment manual is available for a 12-week trial of IPT for adolescents (IPT-A; Mufson et al.
1993). IPT-A is conceptualized as appropriate for adolescents (ages 12–18 years) with
DSM-III-R–defined major depression, normal intellectual functioning, and no active suicidal risk.
Psychotic symptoms, bipolar depression, substance abuse, anxiety disorders, or conduct disorders
generally have been considered contraindications for a trial of IPT-A.
Family-Based Treatments
The need to include the family in the treatment of depressed youth is suggested by studies that
document the importance of family attitudinal and interaction patterns for depressed youth. High
rates of mood disorders are seen among first-degree relatives of depressed youth (Kovacs et al.
1997). The observation that maternal and child depressive episodes may be temporally linked
suggests that symptoms in one member of the parent–child dyad potentiate symptoms in the other
(Hammen et al. 1991). Collectively, these data support an interactional model in which family
stress increases the risk of depression in the children and other family members. This, in turn, can
fuel family stress and dysfunction.
Current data on family-based treatments for depression in youth are limited. Asarnow et al. (2002)
tested a combined cognitive-behavioral and family education intervention in fourth through sixth
graders with depressive symptoms. A family education session followed nine sessions of group CBT,
during which children produced a videotape to help them practice and consolidate skills introduced
in each CBT session. The family education session was designed to promote generalization of skills
to key environmental contexts (home, school, community). After the introduction session, parents
and children were brought together in a multiple-family meeting in which the children’s videotape
illustrating the treatment model was presented and children were given awards for their
accomplishments during CBT. The session ended with each child presenting his or her parent(s)
with an award for their participation in the family session. This intervention was associated with a
greater reduction of depressive symptoms than was observed in a wait-list control group.
Pharmacological Interventions
Despite the current controversy, SSRIs remain the initial antidepressants of choice for patients
requiring pharmacotherapy. However, the presence of comorbid conditions may require alternatePrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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initial agents. For example, a child with MDD and comorbid attention-deficit/hyperactivity disorder
(ADHD) may benefit more from bupropion, venlafaxine, or a tricyclic antidepressant (TCA) than
from an SSRI (American Academy of Child and Adolescent Psychiatry 1998).
Selective Serotonin Reuptake Inhibitors
The SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa),
escitalopram (Lexapro), fluvoxamine (Luvox), and venlafaxine (Effexor), an antidepressant closely
related to SSRIs. Fluvoxamine, sertraline, and fluoxetine are approved by the FDA for treatment of
obsessive-compulsive disorder (OCD) in children. Fluoxetine is also approved for the treatment of
MDD in patients 8 years of age and older. Paroxetine, citalopram, and venlafaxine are prescribed
off-label for children. Improvement with SSRIs may take 4–6 weeks. Thus, patients should be
treated with adequate and tolerable doses for at least 4 weeks. If a patient has not shown even
minimal improvement after 4 weeks and noncompliance is not an issue, a new antidepressant
should be tried. If a patient has improved at 4 weeks, the dose should be continued for 6–9 months
to avoid relapse. The SSRIs have a relatively flat dose–response curve, suggesting that maximal
clinical response may be achieved at minimum effective doses. There is no indication for specific
laboratory tests before (except for thyroid function tests, red blood count, and liver function tests
to check on general health) or during the administration of SSRIs.
Fluoxetine
Fluoxetine is the only medication approved by the FDA to treat depression in children age 8 years
and older. In an 8-week fixed-dosage (20 mg/day) study supported by NIMH, Emslie et al. (1997)
reported that 56% of 97 youths responded to fluoxetine and 33% responded to placebo. In a
9-week trial supported by the manufacturer, Emslie et al. (2002) reported that 52% improved on
fluoxetine versus 37% on placebo. Fluoxetine has also been shown to be effective for relapse
prevention in maintenance treatment (Emslie et al. 2004).
The TADS study (March et al. 2004) compared CBT and fluoxetine treatment, alone and in
combination with each other and placebo. Fluoxetine combined with CBT was superior (71%
response rate) to fluoxetine alone (63% response rate), CBT alone (43% response rate), and
placebo (31% response rate). This is the only randomized clinical trial that has compared the
efficacy of psychological and medication treatments for depression in children and adolescents.
More studies of this nature are needed.
Paroxetine
Paroxetine is not approved by the FDA for any indication in children. There has been one positive
study (Keller et al. 2001) of paroxetine’s efficacy in 12- to 18-year-old depressed adolescents. In
this study, paroxetine was superior to imipramine and placebo in treating depression for all
subjects except those with comorbid ADHD, who did better with imipramine (Birmaher et al. 2000).
In June 2003, the FDA recommended that paroxetine not be used to treat MDD in children and
adolescents because of its unfavorable risk–benefit ratio.
Sertraline
Sertraline is approved by the FDA for the treatment of OCD in children but is not approved for
depression. A multicenter clinical trial of sertraline in depressed youth by Wagner et al. (2003)
reported modest positive results. Sertraline was well tolerated in this study.
Fluvoxamine
Fluvoxamine is approved by the FDA for the treatment of OCD in children but is not approved for
depression in children and adolescents. Clinically, fluvoxamine is used in children and adolescents
with depression who also have OCD.
Citalopram
Citalopram is not approved by the FDA for any indication in children. There is one positive study ofPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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its efficacy in depressed children (Wagner et al. 2004) and one unpublished negative study. The
latter involved both inpatients and outpatients and had a very high dropout rate.
Venlafaxine
Venlafaxine is not approved by the FDA for any indication in children and adolescents. Currently
there are two unpublished negative trials of venlafaxine’s efficacy in depressed children and
adolescents.
Side Effects of SSRIs
The side effects of all SSRIs are fairly similar, are dose-dependent, and may subside with time.
Common side effects include gastrointestinal symptoms, restlessness, diaphoresis, headaches,
akathisia, bruising, changes in appetite or sleep, and sexual dysfunction.
SSRIs may also precipitate a manic or hypomanic episode (Venkataraman et al. 1992) and induce
“behavioral activation,” in which patients become impulsive, silly, agitated, and daring (Riddle et
- 1991).
The FDA has recently adopted a “black box” warning that antidepressants may increase the risk of
suicidal thinking and behavior in children and adolescents with MDD. A black-box warning is the
most serious type of warning in prescription drug labeling. The warning emphasizes that children
and adolescents started on SSRIs should be closely monitored for any worsening in depression,
emergence of suicidal thinking or behavior, and any unusual changes in behavior—such as
sleeplessness, agitation, and withdrawal from normal social situations. This monitoring is especially
important during the first 4 weeks of treatment, although symptoms can also appear after this
initial period.
The current practice guidelines (as per FDA) recommend all pediatric patients being treated with
antidepressants for any indication should be closely observed. Such observation would generally
include at least weekly face-to-face contact with patients and their family members or caregivers
during the first 4 weeks of treatment, then every-other-week visits for the next 4 weeks, then at 12
weeks, and as clinically indicated beyond 12 weeks. Additional contact by telephone between
face-to-face contacts is recommended.
Abrupt discontinuation of SSRIs with shorter half-lives, such as paroxetine, may induce withdrawal
symptoms that mimic a relapse or recurrence of a depressive episode.
Tricyclic Antidepressants
A small study of 22 children treated with imipramine versus placebo reported that children with
abnormal dexamethasone suppression test (DST) response and comorbid anxiety disorders did
better on imipramine than did children with a negative DST response and comorbid conduct
disorder (Preskorn et al. 1987). With TCA use, baseline and follow-up electrocardiogram (ECG)
monitoring for changes in QTc with increasing dose, resting blood pressure, and pulse (supine or
sitting, standing) should be conducted. Also, the clinician should ask about family history of
arrhythmias and syncope as well as family history of congenital hearing problems prior to initiating
TCA treatment (Weller et al. 2004). Off-label use of TCAs may be considered if a child is not
responding to an SSRI, if there is family history of response only to TCAs, or if depression is
comorbid with ADHD and the attentional problems are not responding to the SSRI.
Other Antidepressants
Bupropion, mirtazapine, and nefazodone are used off-label as second- or third-line drugs of choice
for depression. So far, there are no published positive double-blind, placebo-controlled studies
reporting these drugs’ efficacy in the treatment of depression in children and adolescents.
Electroconvulsive Therapy
There have been few reports and literature reviews on the effectiveness of ECT in depressed and
bipolar youth. Rey and Walter (1997) reviewed 154 case reports of teens who had received ECT andPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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found remission or marked improvement in 73% of teens with major depression, 43% with
psychotic depression, 80% with a manic episode, and 73% with bipolar depression. In a separate
study of patient attitudes, 88% believed that ECT was a legitimate treatment, 62% believed that it
was humane, 23% believed that it was cruel, and 19% said that it was outdated. Occurrence of side
effects was similar to psychopharmacology, although memory impairment was much greater in
patients who received ECT (62% vs. 35%). Both indications and response to treatment appear
similar in adolescents and adults. ECT should be considered for a depressed adolescent who does
not respond to conventional treatments and who remains completely dysfunctional or suicidal or
who has a family history of depression that has not responded to any other treatment modality but
ECT. Before ECT is used, two child and adolescent psychiatrists who are not the primary caregivers
for the adolescent should be consulted and should agree that ECT is indicated.
Treatment Algorithm for Major Depressive Disorder
Given the scarcity of research data on effective treatment of depression and optimal use of
antidepressants in children and adolescents, clear guidelines for treatment are essential. Begun in
1996, the Texas Medication Algorithm Project is a collaborative state venture to develop,
implement, and evaluate an algorithm-driven treatment philosophy for major psychiatric disorders
treated in the public mental health sector. In the child and adolescent component of this project,
Hughes et al. (1999) designed a treatment algorithm for children and adolescents with MDD whose
illness is of sufficient severity to warrant medication (e.g., significant psychosocial impairment in
family and peer functioning or school performance, and/or risk of harming themselves or others).
This algorithm is presented in Figure 1–1.
Figure 1–1. Texas Children’s Medication Algorithm Project (CMAP) algorithm for treatment of
children with major depressive disorder.Print: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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Note. SSRI = selective serotonin reuptake inhibitor; MAOI = monoamine oxidase inhibitor; ECT =
electroconvulsive therapy.
Source. Adapted from Hughes CW, Emslie GJ, Crismon ML, et al.: “The Texas Children’s Medication Algorithm
Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Major
Depressive Disorder.” Journal of the American Academy of Child and Adolescent Psychiatry 38:1442–1454,
- Used with permission.
The Texas Consensus Conference Panel agreed to categorize three levels of “data” hierarchically in
formulating stages and differential branching of the treatment algorithm. Level A data consist of
both child and adult randomized controlled clinical trials; level B data consist of open trials and
retrospective analyses; and level C data are case reports and panel consensus as to recommended
current clinical practices. Level A takes precedence over level B, and level B over level C. Consumer
input was also considered.
The algorithm is divided into three phases of treatment: acute, continuation, and maintenance. In
the acute phase, the initial strategy is initiation of a single medication with a favorable side-effect
profile, high safety, and low toxicity. Treatment progresses to the next strategy if there is eitherPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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inadequate symptom improvement or medication intolerance. Hence, intervention can begin with
any of the sequential treatment stages set forth, as long as the rationale is documented (e.g., prior
failure with a level A medication). As one progresses down the algorithm sequence, strategies
become more complicated, may carry greater risk of side effects, require closer monitoring, and
tend to have less empirical support for efficacy and effectiveness, and there is greater reliance on
adult outcome studies.
Treatment of Clinical Variants of Depression
Depression With Suicidal Ideation and/or Attempts
Suicidal depressed youth require a special focus on assessment, monitoring, and amelioration of
suicidality. Suicide risk assessment considers functional impairment, degree of hopelessness,
presence of psychosis, stability of family environment, and quality of available support. If the risk
of suicide is high, treatment in a more restrictive setting (e.g., hospitalization) may be needed.
Outpatient treatment may be appropriate if an adequate safety plan can be developed. All lethal
agents, especially firearms and toxic agents including medications, should be removed from the
home. Individual and family therapy is required for the substance use, school problems, and
physical and sexual abuse that are frequent in suicidal adolescents.
NIMH is supporting the Treatment of Adolescent Suicide Attempters (TASA) study, which is
currently enrolling 120 participants who have recently attempted suicide. Participants will receive
antidepressant medications, CBT, or both in combination. This study should provide important data
on the response of suicide attempts to various treatments.
Psychotic Depression
Patients with psychotic depression appear to recover more rapidly when antidepressants (SSRIs or
TCAs) are combined with antipsychotics. Antipsychotic medications carry the risk of tardive
dyskinesia and therefore should be tapered after remission of the psychosis. Newer atypical
antipsychotic medications, such as risperidone, quetiapine, and aripiprazole, may be useful
alternatives to the older antipsychotics, although there is increased risk for type 2 diabetes and
dyslipidemia (Kane et al. 2004). Anecdotal reports and literature reviews, as mentioned above,
suggest that ECT may be efficacious for psychotic depressed adolescents.
Seasonal Affective Disorder
Studies have reported that bright-light therapy is efficacious for treatment of seasonal affective
disorder in youth. The most widely used protocol is a light box with 10,000 lux at a distance of 1
foot from the face of the patient for 30 minutes per day. Treatment can be extended to 1 hour in
cases of partial response. It appears that patients respond better to treatment during the morning
hours (American Academy of Child and Adolescent Psychiatry 1998).
Bipolar Depression
Signs and symptoms such as psychosis, psychomotor retardation, history of antidepressant induced
mania, or family history of bipolar disorder may suggest that the child may be at risk for a manic
episode. If indicators are present, a prophylactic mood-stabilizing agent, such as lithium carbonate,
valproate, or carbamazepine or lamotrigine, should be considered. For patients who do not respond
to a mood stabilizer alone, an antidepressant should be added. Lamotrigine has been an excellent
treatment for bipolar depression in adults. Lamotrigine is being used widely in children and
adolescents with bipolar depression; however, as yet there are no published double-blind,
placebo-controlled studies documenting its safety or efficacy in children and adolescents. Bipolar
depression will be discussed further in the section on bipolar disorder.
Dysthymic Disorder
Clinical practice and theory support the use of psychotherapies of varying degrees of intensity, CBT,
IPT, and antidepressants to treat dysthymic disorder. In the absence of published studies ofPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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psychotherapeutic or pharmacological treatment of children and adolescents with dysthymic
disorder, interventions recommended for the treatment of youth with MDD may be considered.
Treatment of Comorbid Conditions
Treatment of comorbid conditions is critical to successful outcome. In many cases, psychosocial and
pharmacological treatments used to treat depression may also be useful for treatment of comorbid
conditions. For example, SSRIs and TCAs help both anxiety disorders and MDD; SSRIs may help
both bulimia and MDD (American Academy of Child and Adolescent Psychiatry 1998).
Prevention
Youth with subclinical depressive symptoms are at high risk of developing clinical depression. When
these subclinical symptoms persist after an episode of depression, continued treatment until full
remission occurs is recommended. For patients who have not had an episode of depression,
psychosocial interventions to reduce environmental and family stressors and CBT strategies may
prevent a depressive episode.
Children with dysthymic disorder usually have a first episode of MDD 2–3 years after the onset of
the dysthymic disorder. Thus, dysthymic disorder may be a gateway to recurrent mood disorders
and may indicate a need for early intervention. Early intervention with depressed youth also may
avert the development of comorbid psychiatric disorders. For example, MDD often precedes the
onset of substance use disorders, and successful treatment of the depression may prevent the
substance use development.
TREATMENT OF BIPOLAR DISORDER
General Considerations
Bipolar disorder in children and adolescents is difficult to diagnose and treat. A thorough evaluation
is necessary to diagnose a child with bipolar disorder. It requires a detailed history of both mood
and nonmood symptoms. A comprehensive face-to-face assessment of the child with and without
the parents, including mental status examination, is necessary to rule out pervasive developmental
disorders, language and thought disorders, and psychotic symptoms. Structured and semistructured
interviews may be used to help assess mania in children (Weller et al. 1995). The diagnostic
workup should be done in a systematic fashion. First, manic symptoms secondary to drug use or
general medical conditions should be ruled out. Neurological conditions such as temporal lobe
epilepsy, systemic lupus erythematosus, multiple sclerosis, Wilson’s disease, closed- or open-head
injury, and alcohol-related neurodevelopmental disorder can affect or mimic mood symptoms.
Medications such as TCAs, SSRIs, corticosteroids, sympathomimetic amines, and aminophylline may
increase mood cycling.
Currently, there are no specific laboratory/biological tests for use in diagnosing bipolar disorder in
children and adolescents. Diagnosis is established by considering all of the important data elicited
from taking a history with the parents and the child together and interviewing the parents and the
child separately, as well as obtaining a three-generation family history of psychiatric disorders and
a mental status examination.
Treatment of bipolar disorder is complicated and needs to be tailored to the individual needs of the
child and the family. The child’s symptoms may vary due to the fluctuating nature of the disorder.
Symptoms may also vary with developmental and environmental changes. Therefore, successful
treatment plans require flexibility on the part of the treating clinician. Rating scales such as Young
Mania Rating Scale (Young et al. 1978) can help track severity of target manic symptoms.
Viewing a child’s treatment needs as moving targets is the best way to plan the treatment course of
this complicated illness. Initially the treatment of a bipolar child requires pharmacological
treatment of mood symptoms and dangerousness followed by management of comorbid conditions
such as ADHD and anxiety. Help with functioning at school, assessment of family stress and
caregiver burden, and the mental health treatment of other family members are often needed.Print: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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Hospitalization may be necessary for the treatment of a full-blown manic episode to ensure patient
and family safety. Suicidal threats and gestures must be taken seriously. The family should develop
a crisis plan with the members of the treatment team so parents know how to access the
appropriate services efficiently in emergencies. It is critical that parents are aware of their child’s
mood symptoms, sleep habits, and pattern of cycling so they can make environmental and
behavioral interventions and prevent development of a full-blown episode. In addition, parents
should be aware of the possible educational problems associated with bipolar disorder. The bipolar
child can be unfocused, unmotivated, and lethargic because of mood symptoms or prescribed
medications. Cognitive dullness, fatigue, and poor handwriting may also be linked to medication
treatment. The child can be impulsive, inattentive, anxious, or obsessional because of comorbid
psychiatric conditions. Parents should be educated about the long-term implications of this illness
in regard to schooling and career planning.
Mood-Stabilizing Pharmacotherapy
Once the diagnosis of bipolar disorder has been established, pharmacological treatment is usually
necessary. Before initiating any medication, a baseline laboratory assessment that includes a
complete blood count with differential, thyroid function tests (T3), free thyroxine (T4),
thyroid-stimulating hormone (TSH), electrolytes, blood urea nitrogen, creatinine, creatinine
clearance, urine osmolality, liver function tests, cholesterol, triglycerides, and ECG should be
performed (Weller et al. 2004). These tests are necessary to rule out medical conditions that can
present with manic symptoms and to provide a baseline for medication treatment.
Current treatment of children and adolescents with bipolar disorder is based on clinical trials of
adults with bipolar disorder. There are only limited studies of mood stabilizers in children and
adolescents (Weller et al. 2004). Pharmacological treatment of bipolar disorder has been more
studied among adolescents than among younger children. Thus, guidelines for pharmacological
treatment are relatively more developed for older adolescents.
Mood stabilizers are the mainstay treatment of bipolar disorder. A mood stabilizer is an agent with
efficacy in at least one of the three phases of bipolar disorder treatment (acute mania, acute
depression, or prophylaxis); its use should neither cause an affective switch to the opposite mood
state nor worsen the acute episode.
Wilens et al. (1999) reported that adolescent-onset bipolar disorder was associated with a much
higher risk for substance use disorder compared with childhood-onset bipolar disorder. This
increased risk was not accounted for by conduct disorder or other comorbid psychopathology.
There is a risk of inducing a manic episode with the use of antidepressants in children with
suspected or undiagnosed bipolar disorder. Any child with a three-generation family history of
mood disorder (especially bipolar disorder), rapid-onset depression with or without psychomotor
retardation, and/or psychotic features should be carefully monitored for manic symptoms when
given an antidepressant.
Lithium
Lithium is the oldest and most studied mood stabilizer for adults with bipolar disorder. Controlled
studies have demonstrated its efficacy in the treatment and prevention of manic episodes in adults.
Lithium is approved by the FDA for treatment of bipolar disorder in children 12 years of age and
older.
Although lithium has the longest history of use of any mood stabilizers in youth, there is only one
published double-blind, placebo-controlled trial of lithium treatment of adolescents with bipolar
disorder. Geller et al. (1998) studied 25 adolescents with bipolar disorder and secondary substance
abuse. The 13 subjects treated with lithium for 6 weeks showed a statistically significant decrease
in positive urine toxicology screens for drugs of abuse and a significant improvement in global
assessment of functioning compared with the 12 subjects treated with placebo. The adolescents’
bipolar disorders had preceded their substance abuse by several years. Unfortunately, this studyPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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did not report on the effect of lithium on the adolescents’ mood states.
Kafantaris et al. (2003) studied the initial response of acute manic symptoms to lithium and
attempted to identify predictors of nonresponse in acutely manic bipolar I adolescents. One
hundred 12- to 18-year-olds with an acute manic episode were treated with lithium; 63 met
response criteria and 26 achieved remission of manic symptoms after 4 weeks of treatment.
Prominent depressive features, age at first mood episode, severity of mania, and comorbidity with
ADHD did not distinguish responders from nonresponders. However, psychosis predicted
nonresponse. When treated with adjunctive antipsychotic medication, subjects with psychotic
features at baseline responded as well as subjects without psychosis. In this study, lithium
appeared effective for acute stabilization of symptoms.
There are a few studies on maintenance treatment with lithium in adolescents with bipolar
disorder. In an 18-month naturalistic follow-up of 37 bipolar adolescents who were successfully
treated with lithium during inpatient hospitalization, 13 patients discontinued prophylactic lithium
shortly after discharge. Their relapse rate was nearly three times higher than that of patients who
continued lithium without interruption (Strober et al. 1990). Early relapse among lithium-treated
patients was associated with a greater risk of subsequent relapse.
Varanka et al. (1988) reported a case series of 10 hospitalized prepubertal manic children with
bipolar I disorder. Lithium was used according to the dosing format of Weller et al. (1986). These
children tolerated lithium and reached therapeutic blood levels within a week. Response rate was
comparable to that of adults.
Lithium is relatively well tolerated in children. Side effects have been systematically reported in
children as young as age 3 (Hagino et al. 1995). Common side effects in children include abdominal
discomfort (especially when lithium is taken on empty stomach), weight gain, nausea, diarrhea,
tremor, polyuria and polydipsia enuresis, fatigue, ataxia, leukocytosis, and malaise. Renal, ocular,
thyroid, other neurological, dermatological, and cardiovascular side effects are less common.
Changes in growth, diabetes, and hair loss also have been reported. Children younger than 6 years
may experience increased neurological side effects (Hagino et al. 1995). In general, younger
children seem to experience more side effects than do older children. Thus, their treatment should
be closely monitored for side effects.
Anticonvulsants
Valproate Sodium, Valproic Acid, and Divalproex Sodium
Only a few studies of valproic acid have been conducted in bipolar children and adolescents.
Papatheodorou et al. (1995) treated 15 bipolar adolescents (ages 12–20 years) with divalproex
sodium for 7 weeks. Eight subjects had marked improvement on the Modified Mania Rating Scale
(MMRS), four had moderate improvement, one had some improvement, one had no improvement
and was withdrawn from the study, and one withdrew because of side effects. The mean MMRS
score improved significantly in the 13 subjects who completed the trial.
Kowatch et al. (2000) examined effect sizes for lithium, divalproex sodium, and carbamazepine in
acute-phase treatment of bipolar I or II disorder in 42 children and adolescents (ages 8–18 years).
Response rates measured by the Young Mania Rating Scale were 53% for sodium divalproex, 38%
for lithium, and 38% for carbamazepine. Response rates measured by the Clinical Global
Impressions scale were 40% for divalproex, 46% for lithium, and 31% for carbamazepine. There
were no significant differences among these three for either Clinical Global Impressions scale or
Young Mania Rating Scale response criteria. All three mood stabilizers were well tolerated.
Wagner et al. (2002) treated 40 bipolar children (ages 7–19 years) for 2–8 weeks with valproic
acid followed by an 8-week placebo-controlled period. Sixty-one percent showed greater than 50%
improvement in Young Mania Rating Scale scores during the open-label period. Adverse events
were generally mild or moderate. However, 23 subjects discontinued the study during the
open-label phase, and because only 15 were enrolled in the double-blind phase, statistical analysisPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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could not be done.
Common side effects of valproic acid include sedation, nausea, vomiting, appetite/weight gain, and
tremor. Also, hepatic toxicity, hyperammonemia, blood dyscrasias, alopecia, decreased serum
carnitine, neural tube defects, pancreatitis, hyperglycemia, and menstrual changes have been
reported. Lethal hepatic toxicity appears to occur almost exclusively in very young children,
particularly those younger than 2 years who are on multiple medications (Bryant and Dreifuss
1996).
Vainionpaa et al. (1999) reported increased polycystic ovary syndrome and masculinization in
women who were exposed to valproate during their peripubertal years. Subjects were 41 females
(ages 8–18 years) who were prescribed valproate for epilepsy and 54 healthy control subjects. The
mean serum testosterone concentrations of prepubertal, pubertal, and postpubertal females taking
valproate were significantly higher than those of control subjects at the same pubertal stage.
Hyperandrogenism was seen in 38% of prepubertal, 36% of pubertal, and 57% of postpubertal
females on valproate. This study suggested that valproate might induce hyperandrogenism in
females with epilepsy during the sensitive period of pubertal maturation and that its occurrence
increases with pubertal development. Thus, endocrine assessment of females taking valproate for
epilepsy is recommended.
Rasgon et al. (2000) studied women (ages 18–45 years) who were receiving divalproex
monotherapy (n = 10), lithium monotherapy (n = 10), or divalproex/lithium combination therapy
(n = 2). Hormonal screening did not find polycystic ovary–like changes in any patient. However,
independent of the therapeutic agent used, women in this study reported high rates of menstrual
disturbances. Thus, it is possible that the hypothalamic-pituitary-gonadal axis may be compromised
in some women with bipolar disorder.
Carbamazepine
In an open study, Kowatch et al. (2000) treated 14 children ages 8–14 years with carbamazepine
for 6 weeks. Thirty-eight percent showed at least 50% improvement in symptoms. Common side
effects included nausea, vomiting dizziness, sedation, and rash. Potentially more serious side
effects may include aplastic anemia, agranulocytosis, and hepatotoxicity. Significant drug
interactions can occur, as carbamazepine induces its own metabolism and that of certain other
medications. Currently, a new formulation of carbamazepine (EquetroTM) has been approved in
adults as a treatment for bipolar disorder (Weisler et al. 2005). It is hoped that this medication will
be studied in bipolar children and adolescents in the near future.
Topiramate
A multicenter double-blind, placebo-controlled study of topiramate in children and adolescents was
stopped because of negative findings in adults. DelBello et al.’s (2005) preliminary look at the
limited data seems to show that topiramate may have beneficial effects in bipolar youth, although
the difference between topiramate and placebo response did not reach statistical significance due
to small sample size. Adults and children treated with topiramate complain of word-finding
difficulties, so it is important that this medication be studied before it is widely used. It is also
possible that adolescents liked the topiramate because of its weight-reducing properties rather
than because it helped their mood.
Lamotrigine
Lamotrigine is an anticonvulsant used to treat seizure disorders in children and adolescents.
Randomized controlled trials in adults found that lamotrigine was efficacious for the acute phase of
bipolar disorder and for prevention of depressive episodes. Lamotrigine has FDA approval for
long-term maintenance treatment of bipolar I disorder in adults. It is being increasingly used in
children and adolescents in the depressed phase of bipolar disorder.
Lamotrigine has not been studied in bipolar children, but there are some data on bipolar
adolescents. Carandang et al. (2003) retrospectively studied nine adolescents with refractory moodPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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disorders for whom lamotrigine was added or substituted when previous pharmacotherapy failed.
Seven subjects were “much improved,” one was “very much improved,” and one developed an
erythematous rash that remitted a few days after drug discontinuation.
Lamotrigine’s use in youth with psychiatric disorders is limited because of fears of toxic epidermal
necrolysis. Messenheimer (2002) reported that by lowering the starting dose and slowing down the
titration, the incidence of serious rash in pediatric lamotrigine declines to about 1%.
Gabapentin
No published double-blind, placebo-controlled studies of bipolar children or adolescents treated
with gabapentin have been published.
Oxcarbazepine
No multicenter double-blind, placebo-controlled studies in children and adolescents have yet been
published, and it is unclear whether oxcarbazepine is superior to placebo.
Antipsychotics
Several atypical antipsychotics are approved for treatment of mania in adults. Thus, there is
growing interest in studying their use in children with bipolar disorder.
Risperidone
Eighty-two percent of 28 children and adolescents (ages 4–17 years) in a retrospective chart
review showed improvement in manic and aggressive symptoms after adjunctive treatment with
risperidone (Frazier et al. 1999).
Spencer et al. (2003) found that risperidone monotherapy was associated with a good response
after 8 weeks in 30 youths with bipolar disorder (ages 6–17 years). Significant metabolic findings
included prolactin increase and an average weight gain of 2 kg over 2 months. Clinical experience
shows greater weight gain in children and adolescents treated with risperidone than in similarly
treated adults. An ongoing double-blind, placebo-controlled multicenter study is examining the
safety and efficacy of risperidone in bipolar children and adolescents ages 10–17 years.
Olanzapine
An 8-week open-label, prospective study of olanzapine monotherapy in 23 bipolar youths (ages
5–14 years) found that olanzapine was associated with significant improvement and was well
tolerated, although significant weight gain was reported (Frazier et al. 2001).
Quetiapine
DelBello et al. (2002) studied the adjunctive use of quetiapine in 30 manic or mixed bipolar I
adolescents (ages 12–18 years) who were on divalproex. The divalproex plus quetiapine group had
a greater reduction in Young Mania Rating Scale scores from baseline to endpoint than did the
divalproex plus placebo group. In general, quetiapine was well tolerated when used in combination
with divalproex, although there was mild to moderate sedation and a greater dropout rate than in
the placebo group.
McConville et al. (2003) studied the long-term use of quetiapine in 10 youths (ages 12–15 years)
with schizoaffective disorder or bipolar disorder with psychotic features (n = 3). No extrapyramidal
symptoms or evidence of tardive dyskinesia was observed. There was a nonsignificant increase in
mean body mass index at week 64. This 88-week study found that quetiapine was well tolerated
and may be efficacious for the treatment of psychotic symptoms in affective psychoses in
adolescents. A multicenter double-blind, placebo-controlled study to assess quetiapine’s safety and
efficacy in bipolar children is currently in progress.
Ziprasidone
There are no controlled studies on ziprasidone’s use in children and adolescents.Print: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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Aripiprazole
A multicenter double-blind, placebo-controlled study is currently being conducted to examine the
efficacy and safety of aripiprazole in bipolar children and adolescents.
Clozapine
Clozapine has been reported to be effective in adults with treatment-resistant bipolar disorder. Masi
et al. (2002) also reported on the therapeutic effect of clozapine in 10 adolescent inpatients (ages
12–17 years) with severe acute manic or mixed episodes who did not improve after treatment with
conventional drugs (mood stabilizers or antipsychotics). At hospital discharge after 15–28 days of
clozapine treatment, all patients had responded. Side effects (increased appetite, sedation,
enuresis, sialorrhea) were frequent but not severe enough to require dosage reduction. Mean
weight gain after 6 months was 6.96 ± 3.08 kg. Neither decrease of white cells nor epileptic
seizures were reported during follow-up (12–24 months). These findings suggest that clozapine
might help adolescents with treatment-refractory manic or mixed episodes.
Significant Side Effects of Atypical Antipsychotics
Because of recent reports of obesity and metabolic changes associated with the use of atypical
antipsychotics in adults, Kane et al. (2004) examined weight gain and metabolic abnormalities in
103 children and adolescents (ages 5–18 years) on quetiapine, olanzapine, and risperidone for any
diagnosis. All three atypical agents were found to have caused weight gain and increased body fat,
often deposited abdominally, at 12 weeks. Weight gain with olanzapine and risperidone was greater
than that with quetiapine. Children in all three groups had increased triglyceride levels and insulin
resistance. New-onset dyslipidemia was reported in about one-third of the patients. Weight should
be monitored monthly, and lipids and fasting glucose every 3–6 months, in youth treated with these
atypical antipsychotics.
Polypharmacy
Monotherapy is ineffective for many children and adolescents with bipolar disorder, leading to a
trend toward polypharmacy. Findling et al. (2003) examined the effectiveness of combining lithium
with divalproex sodium in 90 bipolar children (ages 5–17 years) over 20 weeks. Significant
improvement was found in all outcome measures at week 8 and at the end of the study. The
combination was well tolerated.
Kafantaris et al. (2001) examined the use of antipsychotic medications in combination with lithium
in 28 adolescents (ages 12–18 years) with bipolar and psychotic features. Improvement was
noticed in 64% after 4 weeks of treatment with lithium and either haloperidol or risperidone, but
few maintained their response after antipsychotic medications were discontinued. Successful
discontinuation of antipsychotic medication was associated with current episode being the first
episode, shorter duration of psychotic symptoms, and presence of thought disorder. The authors
concluded that adjunctive antipsychotic medication needed to be maintained for longer than 4
weeks in most adolescents with psychotic mania, even if manic and psychotic symptoms have
resolved and lithium treatment is maintained.
Electroconvulsive Therapy
ECT is rarely used in children and adolescents but is considered for adolescents with severe
treatment-resistant bipolar depression (Rey and Walter 1997).
Treatment of Bipolar Depression
Pharmacological treatment of bipolar depression is not well studied in adults. Only lamotrigine and
an olanzapine/fluoxetine combination are approved for acute treatment of mania. Very limited
information is available to guide treatment of bipolar depression in children and adolescents.
Lithium has shown efficacy in bipolar depression in adults. Geller et al. (1998) examined the use of
lithium in the treatment of depression in prepubertal children in a 6-week double-blind,Print: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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placebo-controlled study. These investigators had hypothesized that depressed children with family
history predictors of future bipolar disorder would respond better to lithium; however, they found
no significant differences.
Psychosocial Treatments
In adults, CBT and family-focused therapy reduced the number of depressive episodes and
extended the time to relapse/recurrence of depression in bipolar patients (Miklowitz et al. 2003).
In a literature review, Fristad et al. (2002) reported that psychosocial treatments for children with
bipolar disorder were nonexistent.
Research on psychosocial factors that may affect outcome for young patients with bipolar disorder
is limited. One study by Geller et al. (2002) found that lack of maternal warmth predicted relapse.
Living in an intact family was associated with faster recovery.
Psychotherapy
Studies in unipolar depressed youth found CBT and IPT are efficacious for acute treatment of
depression (Mufson et al. 1999). No such data are available for various phases of bipolar disorder.
Family Interventions
A child with bipolar disorder produces a host of issues for other family members. To maximize the
psychological well-being of all involved, issues associated with bipolar disorder need to be
addressed immediately and consistently. Parents must become specialized caregivers. The family
must have access to a clinician who is knowledgeable about and can adapt to the vicissitudes of
bipolar disorder. Treatment plans must be tailored to the family’s needs.
Fristad et al. (2002) reported that multifamily psychoeducational groups (MFPGs) were efficacious
for bipolar children.
Support Groups
Caregivers of children with bipolar disorder often experience emotional, physical, and financial
stress. Some sources of emotional stress are their child’s rejection by peers, school failure, rage
attacks, suicide attempts, and unpredictable behavior. Caregivers often live in a state of
hypervigilance. Many children with bipolar disorder require special education services or enter the
juvenile justice system. Caregivers can become confused, misunderstood, and overwhelmed and
may experience physical problems such as sleep disturbance, headaches, and exhaustion. These
families can also suffer isolation because of stigmatization. Support groups can be helpful in
dealing with these stressors.
Internet Resources
Sisson and Fristad (2001) found that online support groups for parents who feel isolated were
extremely useful. The Child and Adolescent Bipolar Foundation (CABF) web site (www.bpkids.org)
provides scientific information on the diagnosis, symptoms, and treatment of early-onset bipolar
disorder. Other helpful web sites include those of the Depression and Bipolar Support Alliance
(DBSA; www.ndmda.org), the National Alliance for the Mentally Ill (NAMI; www.nami.org), and
NIMH (www.nimh.nih.gov).
Bipolar Treatment Algorithms
Medication treatment algorithms for acute-phase treatment of children and adolescents ages 6–17
years who meet DSM-IV-TR (American Psychiatric Association 2000) criteria for bipolar I disorder,
manic or mixed episode, have recently been developed (Kowatch et al. 2005). The Texas Consensus
Conference Panel established four levels of evidence: Level A data consist of randomized controlled
clinical trials in children; level B data consist of randomized clinical trials in adults; level C data are
open trials and retrospective analyses; and level D data are case reports and panel consensuses on
recommended current clinical practices. Higher-level data took precedence in determining
treatment recommendations.Print: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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Algorithm I: Bipolar I Disorder, Manic or Mixed, Acute, Without Psychosis
Stage 1: Monotherapy
The first-line treatment is monotherapy with the traditional mood stabilizers lithium, divalproex,
and carbamazepine and the atypical antipsychotics olanzapine, quetiapine, and risperidone. The
comparative efficacy of these agents has not been well studied. The majority of the panel
recommended lithium or divalproex as the first medication of choice for nonpsychotic mania. Both
the clinical experience of the clinician in the use of these agents and the side-effect profiles of the
medications must guide initial monotherapy selection for a given child. Ziprasidone, aripiprazole,
and oxcarbazepine may be included in this group as new data become available.
Stage 1A: Monotherapy Plus Augmentation
Children who have had only a partial (moderate to minimal) improvement with initial monotherapy
should receive an augmenting agent. Some panel members recommended combining lithium and
divalproex before combination treatment with an atypical antipsychotic for nonpsychotic mania. If
initial monotherapy with an atypical antipsychotic resulted in a partial response, then lithium,
divalproex, or carbamazepine could be the added to the treatment.
Stage 2: Alternate Monotherapy
For children who had no response to the initial monotherapy or who had intolerable side effects,
monotherapy with one of the other medications not tried in stage 1 is recommended.
Stage 2A: Alternate Monotherapy Plus Augmentation
If a child has a partial response to the monotherapy agent selected in stage 2, then augmentation
with an agent not used in stage 1 is indicated.
Stages 3A and 3B: Monotherapy or Combination of Two Mood Stabilizers
Panel members were divided in their opinion about treatment strategy when a child with a mixed or
manic episode had tried two monotherapy agents without success. Some panel members believed
selection of monotherapy agents not tried in stages 1 and 2 would be a reasonable choice to reduce
the likelihood of side effects and to increase compliance (stage 3A). It was also the opinion of these
panel members that lack of response to two monotherapy agents did not predict failure of an agent
of a different class. Other panel members felt that a child for whom two monotherapy trials had
failed would be unlikely to respond to a third monotherapy agent and would recommend a
combination of two mood stabilizers (stage 3B).
Stages 4A and 4B: Combination of Two Mood Stabilizers or Three Mood Stabilizers
For children who had no response or a partial response to monotherapy in stage 3A, stage 4A
recommendation is a combination of two mood stabilizers or atypical antipsychotics. Stage 4B is for
those children who had no response or a partial response to augmentation with a monotherapy
agent (stage 2A) or who had no response or a partial response to a combination of two mood
stabilizers (stage 3B). In this stage, these children would receive a combination of three mood
stabilizers or atypical antipsychotics.
Stage 5: Alternate Monotherapy
Trials of alternate monotherapy with level D agents such as oxcarbazepine, ziprasidone, or
aripiprazole were considered stage 5 treatments.
Although there is past clinical experience (level D) with typical antipsychotics, the atypical
antipsychotics have the advantage of a more tolerable side-effect profile.
Stage 6: Electroconvulsive Therapy or Clozapine
Children who did not show a positive response or who experienced intolerable side effects to all
previous treatment stages should receive clozapine. Only adolescents should receive ECT.Print: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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Algorithm II: Bipolar I Disorder, Manic or Mixed, Acute, With Psychosis
Stage 1: Mood Stabilizer Plus Atypical Antipsychotic
For children with bipolar I disorder, manic or mixed with psychosis, initial treatment with a
combination of a traditional mood stabilizer (lithium, divalproex, or carbamazepine) and an atypical
antipsychotic based on level C was recommended. Divalproex plus an atypical antipsychotic or
carbamazepine plus an atypical antipsychotic, based on clinical experience (level D), was
recommended as a treatment option.
Stage 1A: Augmentation
For children whose symptoms do not respond to a mood stabilizer plus an atypical antipsychotic,
combination treatment with three medications is recommended, based on clinical experience (level
D). In this case, lithium plus divalproex plus an atypical antipsychotic or lithium plus
carbamazepine plus an atypical antipsychotic could be the treatment regimen.
Stage 2: Mood Stabilizer Plus Atypical Antipsychotic
A combination of medications not tried in stage 1 is recommended.
Stage 2A: Augmentation
If a child has a partial response to stage 2A treatment, augmentation is recommended, based on
clinical experience (level D). For example, lithium plus divalproex plus an atypical antipsychotic
would be an option.
Stage 3: Mood Stabilizer Plus Alternate Atypical Antipsychotic
In this stage it is recommended that an alternate atypical antipsychotic be added to the mood
stabilizer. For example, if the child had been treated with lithium and risperidone in stage 2, then
lithium plus a different atypical antipsychotic would be a possible treatment combination.
Stage 3A: Lithium Plus Divalproex or Carbamazepine Plus Alternate Atypical
Antipsychotic
If a child’s symptoms fail to respond to stage 2A treatment with lithium plus divalproex plus an
atypical antipsychotic or to lithium plus carbamazepine plus an atypical antipsychotic, a switch to
an alternate atypical antipsychotic is recommended.
Stage 4: Combination of Two Mood Stabilizers Plus Atypical Antipsychotic
For children who have not responded to treatment with lithium and two atypical antipsychotics,
divalproex and two atypical antipsychotics, or carbamazepine and two atypical antipsychotics,
combination treatment of two mood stabilizers plus an atypical antipsychotic is recommended,
based on clinical experience (level D).
Stage 5: Alternate Monotherapy Plus Atypical Antipsychotic
If medications used in stages 1 through 4 all fail, then alternate monotherapy (oxcarbazepine) plus
an atypical antipsychotic is recommended, based on clinical experience (level D).
Stage 6: ECT or Clozapine
For children and adolescents who have not responded to combination treatment with three
medications, clozapine is recommended. ECT is recommended for adolescents only.
Acute-Phase Treatment for Bipolar I Disorder, Depressed
The Texas Consensus Conference Panel agreed that there was insufficient evidence to develop a
treatment algorithm; however, they did make a few recommendations.
Lithium was recommended as a treatment option for bipolar depression in children and adolescents
based on level B data. There are (level C) data for SSRI use in bipolar depression, but the SSRIsPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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had destabilizing effects in some bipolar youth. Another antidepressant treatment option is
bupropion, based on clinical experience (level D). It was recommended that SSRIs and bupropion
be used as adjunctive treatments to a mood stabilizer after mood is stabilized. It was recommended
that antidepressant medication be continued for at least 8 weeks after remission of depressive
symptoms. In children, other treatment alternatives are lamotrigine, which has level D evidence
and clinical experience, and divalproex, based on clinical experience (level D).
ECT should be considered only for adolescents with severe treatment-resistant bipolar depression.
Summary of Pediatric Bipolar Disorder
Almost every aspect of the pediatric bipolar disorder needs more study. Children with bipolar
disorder are a high-risk group with multiple comorbidities. They often have very poor functioning at
school, at home, and with their peers. It is hoped that with the recent surge of interest in bipolar
disorder, more systematic studies will lead to a better understanding and improved treatment.
Drug–drug interactions, factors associated with outcome, and psychosocial interventions all need
further study.
TREATMENT OF SUICIDAL BEHAVIORS
As treatment for suicide centers around prevention, it is important to understand factors that
increase suicide risk.
Youth Characteristics
Age
Completed suicides and suicide attempts are relatively rare among prepubertal children but
increase in frequency through the early 20s, most markedly in the late teens. In 2000, the suicide
mortality rate for 10- to 14-year-olds in the United States was 1.5 per 100,000. The suicide
mortality rate for 15- to 19-year-olds was five times the rate of the younger age group.
Psychopathology
Most youth who complete suicide or make serious suicide attempts have had at least one major
psychiatric disorder. Depressive disorders are most prevalent among adolescent suicide victims,
occurring in 49%–64%, with females more likely than males to have an affective disorder (Brent et
- 1999). Substance abuse is a significant risk factor, especially among older adolescent males.
Shaffer et al. (1996) reported disruptive disorders to be common in male teenage suicide victims.
Pilowsky et al. (1999) reported panic attacks to be associated with an increased risk of suicidal
behavior in adolescents. Several investigators (e.g., Andrews and Lewinsohn 1992) reported that
psychiatric problems and gender-specific diagnostic profiles of youth suicide attempters and
completers were similar. However, Gould et al. (1998) reported differences in the diagnostic
profiles of attempters and ideators. For example, substance abuse/dependence is more strongly
associated with suicide attempts than with suicidal ideation.
Prior Attempts
A history of a prior suicide attempt is one of the strongest predictors of completed suicide,
particularly in males (Shaffer et al. 1996).
Youth Personality/Cognitive Factors
Hopelessness, depression, and suicidal ideation are risk factors for a suicide attempt (Mann et al.
1999). Horesh et al. (2003) studied 65 depressed and borderline adolescents (ages 13–18 years)
and found that depression and hopelessness were equally related to suicidal behavior in both
borderline and MDD groups but that aggression and impulsiveness were positively correlated with
suicidal behavior only in borderline adolescents.
Apter et al. (2001) found that reluctance for self-disclosure was significantly higher in more serious
attempters and did not appear to be mediated by depression, anxiety, or hopelessness.Print: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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Self-disclosure might be a promising field for assessment, therapy, and prevention for suicidal
patients.
A two- to sixfold increase in nonlethal suicidal behavior has been found in homosexual and bisexual
youth compared with heterosexual youth (Russell and Joyner 2001).
Biological Factors
A substantial body of knowledge has accumulated on biological factors in suicide. Most of the work
has focused on serotonin dysregulation in suicidal, impulsive, and aggressive individuals,
regardless of psychiatric diagnosis. Mann and Stoff (1997) suggest this dysregulation is a biological
trait that predisposes to suicide. A mentally ill person with this diathesis is more likely to respond
to a stressful experience in an impulsive fashion that may include a decision to commit suicide.
Given the observed family history of suicidal behaviors, some investigators (e.g., Mann and Stoff
1997) have focused on a search for candidate genes that might be involved in the inheritance of a
“suicidogenic factor.”
Family Characteristics
Family History of Suicidal Behavior
Youth suicide is nearly five times more likely in the offspring of mothers who have completed
suicide and twice as likely in the offspring of fathers who completed suicide (Agerbo et al. 2002).
Twin data from all age groups show that first-degree relatives of suicide completers have more
than twice the risk of the general population. The relative risk was increased among the identical
twins of suicide completers to 11-fold. The estimated heritability for completed suicide was 43%
(McGuffin et al. 2001).
Parental Psychopathology
High rates of parental psychopathology, particularly depression and substance abuse, are
associated with suicidal behavior in adolescence (Fergusson and Lynskey 1995).
Parent–Child Relationships
The association between impaired parent–child relationships and increased risk of suicidal behavior
among youth is unclear. Some investigators (Fergusson et al. 2000) have found that the association
is mediated by the youth’s psychological problems.
Youth Life Circumstances
Stressful Life Events
A strong relationship between serious suicidal behavior and life stressors (e.g., breaking up with a
girlfriend/boyfriend, having disciplinary problems) has been identified even after adjusting for
other important factors (Fergusson et al. 2000). Interpersonal losses are more common among
suicide victims with substance abuse disorders. Legal or disciplinary crises are more common in
victims with disruptive disorders or substance abuse disorders. Bullying (either as victim or
perpetrator) is associated with increased risk for suicidal ideation (Kaltiala-Heino et al. 1999).
Physical and Sexual Abuse
Johnson et al. (2002) found that childhood physical abuse was associated with an increased risk of
suicide attempts in late adolescence or early adulthood. The authors suggested that physically
abused children might have difficulty developing the social skills necessary for healthy
relationships, leading to social isolation and/or antagonistic interactions. This would lead to
increased risk for subsequent suicidal behavior.
An association between physical abuse and suicide has been reported in a psychological autopsy
study (Brent et al. 1999) and replicated in prospective longitudinal community studies (Johnson et
- 2002). Similarly, self-reported child sexual abuse was significantly associated with an increasedPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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risk of suicidal behavior in adolescence.
Socioeconomic Status
Some have reported that youth suicide attempters have higher rates of socioeconomic disadvantage
compared with community samples (Fergusson et al. 2000). However, Agerbo et al. (2002)
reported that socioeconomic disadvantage is not a major risk factor for suicide.
School and Work Problems
Wunderlich et al. (1998) reported that high school dropouts were at significant risk for suicidal
behavior.
Contagion/Imitation
Evidence supports the idea of suicide contagion. The media also has an impact on suicidal behavior
(Brent et al. 1989).
Treatment
Identifying youth at risk for suicide is crucial. Focusing preventive efforts on this population is the
most effective way to combat this serious problem. Thus, the most expedient approach to decrease
suicidal behavior is to treat the underlying disorders with suicidal behavior as a symptom. Many
adolescents contact a mental health professional before initiating suicidal behavior (Shaffer et al.
1996). Unfortunately, few studies have systematically evaluated interventions that might help
reduce suicidal ideation and behavior. In fact, most studies exclude suicidal patients.
Emergency/Crisis Service Interventions and Triage Services
Emergency/crisis intervention services try to ensure that certain preconditions (e.g., safety in the
house) are satisfied before suicidal children and adolescents are discharged from emergency
services. A written or verbal “no-suicide contract” is commonly negotiated at the start of treatment,
although no empirical studies have evaluated their effectiveness.
Rotheram-Borus et al. (1999) found they could increase eventual treatment adherence in Latino
patients by 1) using a standardized protocol for training emergency room staff, 2) presenting a
20-minute videotape to patients and their families that models realistic expectations for aftercare
treatment, and 3) providing a bilingual crisis therapist to promote compliance with outpatient
therapy.
Inpatient Care and Partial Hospitalization
Hospitalization serves as a valuable protective and assessment tool. Hospitalization is unavoidable
if the youth is not willing to engage in a no-suicide contract. It also may be necessary to medicate
depressed suicidal youth in a protected setting. Inpatient care offers intensive multidisciplinary
treatments, skilled observation, and support, but there is no empirical evidence showing that
inpatient care is effective in reducing suicidal ideation, nonlethal attempts, or completed suicide
among adolescents.
Psychotherapy
An adolescent version of dialectical behavior therapy (Miller et al. 1997) may be valuable but lacks
systematic evaluation.
There are a few studies of CBT with severely depressed suicidal adolescents. Barbe et al. (2004)
recently reported that CBT has a specific beneficial effect on suicidal ideation. Brent and Apter
(2003) suggested that constructs such as decreased hopelessness might serve to moderate and
mediate CBT treatment outcome in suicidal adolescents. The TADS study (March et al. 2004)
showed that CBT combined with fluoxetine has a protective effect against suicidal ideation and
harm-related behaviors.
Psychopharmacological InterventionsPrint: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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There has been a recent decline in suicide rates in youth. Olfson et al. (2003) suggested that this
suicide rate reduction could be related to the increase in antidepressants prescribed for adolescents
between 1987 and 1996, when antidepressant use increased from 0.3% to 1.0% of youths 6–19
years of age in the United States. Controlled studies are needed to determine whether this is a
meaningful correlation. The possible benefits hinted at by this correlation make the recent
controversy over SSRI use and suicidal ideation problematic. Antidepressant use among patients
younger than 18 years decreased following the FDA’s October 2003 Public Health Advisory
reporting increased risk of suicidality in children being treated with certain antidepressants
(Henning 2004). The long-term impact of a decline in prescribing SSRIs to depressed children and
adolescents remains to be seen.
Although the antisuicidal effects of lithium have not been assessed in children or adolescents,
Tondo and Baldessarini (2000) have found that sudden withdrawal from lithium increases the risk
of suicide.
Suicide Prevention Strategies
Youth suicide prevention strategies generally have one of two general goals: finding cases and
referring for treatment or risk-factor reduction (Gould and Kramer 2001). They primarily have been
implemented within three domains—school, community, and health care systems.
School-Based Suicide Prevention Programs
Suicide Awareness Curriculum
There is not yet enough evidence to judge programs that facilitate self-disclosure and prepare
teenagers to identify at-risk peers and take responsible action.
Skills Training
Skills training programs emphasize development in areas in which suicidal youths have deficits,
such as problem solving, coping, and cognitive skills. Reduction of suicide risk factors (depression,
hopelessness, drug abuse) is also a targeted outcome. Programs that focus on skills training and
social support programs for students at high risk for school failure or dropout have shown
enhancement of protective factors and reductions in risk factors following the “active” intervention
(Thompson et al. 2001).
Screening
Direct screening, self-report, and individual interviews are used to identify youngsters at risk for
suicidal behavior. Schoolwide screenings have focused on depression, substance abuse, recent and
frequent suicidal ideation, and past suicide attempts. Sensitivity of the screens ranged from 83% to
100%; specificity ranged from 51% to 76% (Shaffer and Craft 1999). Thus, there were few false
negatives but many false positives. The seriousness of missing a suicidal individual precludes using
more stringent cutoff criteria to minimize false positives.
Although promising, screening is labor intensive. High school principals find student screening
programs less acceptable than curriculum-based and staff in-service programs (Miller et al. 1999).
It is important to note that the success of screening is dependent on the effectiveness of the
intervention once a suicidal adolescent has been identified.
Gatekeeper Training (Staff In-Service Training)
The purpose of gatekeeper training is to develop the knowledge, attitudes, and skills in school
personnel necessary to identify students at risk, determine the levels of risk, and make referrals
when necessary. Although an overwhelming majority of counselors reported that they knew the risk
factors for suicide, only one in three believed that they could identify a student at risk. Gatekeeper
training is effective in improving school personnel’s knowledge, attitudes, intervention skills,
preparation for coping with a crisis, and referral practices (King and Smith 2000).Print: Chapter 1. Mood Disorders and Suicidal Behavior http://www.psychiatryonline.com/popup.aspx?aID=250004&print=yes…
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Peer Helpers
The role peers play varies considerably by program and ranges from listening and reporting
possible warning signs to being involved in counseling. Many programs address serious mental
health problems, such as drug abuse, eating disorders, and depression. Empirical evaluations of
these programs are limited.
Postvention/Crisis Intervention
School-based postvention/crisis intervention is based on the premise that a timely response to a
suicide is likely to reduce subsequent morbidity and mortality in fellow students. Research on
school-based postvention programs is sparse.
Community-Based Prevention Programs
Crisis Centers and Hotlines
Suicidal behavior is often associated with a crisis, and telephone crisis services can provide
immediate support at critical times. These services should be convenient, accessible, and available
outside business hours.
Between 1% and 6% of adolescents in the community use hotlines (Vieland et al. 1991), but there
is little information on the efficacy of telephone crisis services for teenagers.
Restriction of Firearms
Because having guns in the house is considered a risk factor for suicide in youth (Brent et al. 1999)
and firearms are the most common method of committing suicide in the United States (U.S. Centers
for Disease Control and Prevention 2002), it would seem that restricting access to firearms during
high-risk periods might help prevent suicide. However, despite the restriction of access to firearms
after the passing of the Brady Bill in 1994, there was no decrease in the proportion of suicides by
firearms between 1988 and 1999 (Cutright and Fernquist 2000). The effects of restrictive gun laws
on suicide in specific age groups remain unclear.
Less controversial means-restriction measures involve education of parents of high-risk youths.
Unfortunately, Brent et al. (2000) found that parents of depressed adolescents were frequently
noncompliant with recommendations to remove firearms from the home.
Media Education
Given the substantial evidence for suicide contagion, a recommended suicide prevention strategy is
educating media professionals. Recommendations on reporting of suicide were recently developed
by an international workgroup headed by the American Foundation for Suicide Prevention and the
Annenberg School of Communication and Public Policy (American Foundation for Suicide Prevention
2001).
Health Care–Based Prevention Programs
Fewer than half of physicians surveyed reported that they routinely screen their patients for suicide
risk (Frankenfield et al. 2000).
CONCLUSION
Given the complexity of the mechanisms of youth suicide, it seems likely single no
prevention/intervention strategy is enough to combat this public health problem. Rather, a
comprehensive, integrated effort that includes multiple domains—the individual, family, school,
community, media, and health care system—is needed. Well-designed intervention studies that
include medications, psychotherapies, and environmental interventions are urgently needed.
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Copyright © 2009 American Psychiatric Publishing, Inc. All Rights Reserved.
Course Content
Introduction to Mood Disorders and Suicidal Behavior
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Overview of Mood Disorders
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Understanding the Causes of Mood Disorders
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Identifying Symptoms and Signs of Mood Disorders
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Introduction to Suicidal Behavior
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Quiz on Mood Disorders and Suicidal Behavior Basics
Identifying and Diagnosing Mood Disorders
Understanding the Causes and Risk Factors of Suicidal Behavior
Treatment Approaches and Strategies for Mood Disorders
Conclusion and Future Directions in Mood Disorder Research
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