Clinicians could be on the brink of a much greater understanding of the relatively new diagnosis of disruptive mood dysregulation disorder (DMDD) in children, including more evidence on whether selective serotonin reuptake inhibitors (SSRIs) offer the most promising direction in treatment, Julie Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, said at Psych Congress 2020.
Dr. Carbray, clinical professor of psychiatry and nursing at the University of Illinois at Chicago, discussed the challenging task of distinguishing DMDD from other behavioral disorders in childhood, such as bipolar disorder and attention-deficit/hyperactivity disorder (ADHD). Marked by extreme irritability and outbursts of anger that occur at least 3 times a week and are disproportionate to the situation, DMDD first appeared as a diagnosis with publication of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) in 2013. DMDD is more common in males and heightens risk of depression, anxiety, and suicidality later in life.
“It's not a mild disorder,” Dr. Carbray said. “This is a disorder that can have significant manifestations over time for children and adolescents as they grow into adulthood.”
There are no federally approved medication treatments for DMDD, with early research pointing to SSRIs such as citalopram as a promising course (used in combination with a stimulant where comorbid ADHD is present). However, Dr. Carbray added that evidence of the efficacy of SSRIs and other antidepressants for DMDD remains inconclusive, with no duplication of initial study findings as of yet.
The field is still learning how to differentiate between DMDD and bipolar disorder, Dr. Carbray said. Children with DMDD may tend to first present with developmental disorders and ADHD, which later could manifest as mood dysregulation in adolescents and depressive symptoms in adulthood. A key difference from bipolar disorder lies in the lack of episodic symptomatology (hypomania, elation) among patients with DMDD, she said.
Dr. Carbray, a member of the Psych Congress Steering Committee, cited numerous tools that can assist in the screening of children, from the free Vanderbilt ADHD Diagnostic Rating Scale to the Child Mania Rating Scale developed at her university.
“In these days of telepsychiatry, having one that's public domain and fairly accessible to families has also been helpful,” she said. She emphasized, however, that screening tools are not diagnostic and cannot substitute for a comprehensive clinical interview.
Dr. Carbray's virtual session addressed topics submitted in advance as questions from Psych Congress attendees. In response to several questions related to pharmacologic treatments:
She said she always will have a start-up conversation with a young patient and family before initiating a stimulant, to discuss issues such as safety, diversion risk, and any other substances the young person is using. “If I feel that there is or has been diversion or misuse, then it's sort of a deal-breaker for my ongoing prescription of your stimulants,” Dr. Carbray said. “You as a clinician have oversight over your practice and you need to be comfortable with your prescription of these types of medications for your patients.” She uses verbal agreements with patients, though she said some practices prefer written contracts.
She said atypical antipsychotics generally should not be used to manage behavior, although they may address issues such as aggression that are associated with an underlying mood state. Federal guidance suggests that atypicals should not be first-line treatment for youths, and always should be used in combination with psychosocial interventions.
She said that not only is lithium indicated for bipolar disorder in children and adolescents, but data from the Collaborative Lithium Trial suggest that children generally need a higher dose than originally thought, and can have their dosing increased more quickly than what has traditionally been accepted.
“Solving Clinical Challenges in Child and Adolescent Psychiatry.” Presented at Psych Congress 2020: Virtual; September 10, 2020.