Mood Disorders in Young People: Effective Treatment Strategies

Major depression and bipolar disorder in children and adolescents can be effectively treated. However, an early diagnosis, followed by appropriate intervention, is crucial to allow for a normal life trajectory, including finishing school and holding down a job, according to Adelaide Robb, MD.

“That’s the key,” said Dr. Robb, Professor of Child and Adolescent Psychiatry, George Washington University and Children’s National Health System, Washington, DC. She has served as principal investigator of more than 70 pediatric psychopharmacology trials in children and teenagers.

Unfortunately, many children and adolescents with mood disorders do not receive the care they require—in part because they often see psychiatrists who lack the experience in working with this population.

“What tends to happen is people are nervous about treating kids,” she said. “They will begin them at half the normal starting dose and then leave the patients there. They’re not going to get better that way.”

An Intimate Look at the Future of Advanced Psychopharmacology

Dr. Robb does not necessarily blame psychiatrists who specialize in adults for their apprehension with treating younger patients. She said they likely have limited background in pediatric mood disorders, doing just a 3- to 6-month rotation primarily around attentiondeficit/ hyperactivity disorder (ADHD) in elementary school-age children.

However, Dr. Robb said that knowledge gap can be closed by taking continuing medical education (CME) courses and attending conferences, such as Psych Congress, where she will be presenting “Treating Children and Adolescents with Mood Disorders.”

“Gaining comfort in treating children with mood disorders will enhance the level of care for the pediatric patients in your practice,” she stressed.

Dr. Robb, who sees young patients with a variety of psychiatric disorders in inpatient and outpatient settings, will focus much of the session on the treatment of major depression and bipolar disorder in children and adolescents.

Medication is the first-line option for bipolar disorder, with lithium, an antiepileptic, or an antipsychotic as the go-to options. “Just the way it is with adults,” she said, noting supportive psychotherapy, family-focused therapy, and cognitive behavioral therapy (CBT) as established secondary treatments.

On the other hand, treatment for depression depends on the severity, she said. For mild symptoms of major depression, strong evidence supports the use of CBT or interpersonal therapy, but in cases of moderateto- severe major depression, medication works faster and is more effective.

For example, Dr. Robb cites the major National Institutes of Health (NIH)-funded Treatment for Adolescents With Depression Study (TADS). The trial showed for the first 12 weeks of treatment, CBT offered no advantage over placebo in terms of reducing depressive symptoms in teens with major depression who had moderate level severity.

“It took about 9-18 months for the symptom improvement on CBT alone to equal the level of symptom improvement that happened on fluoxetine,” she said.

In addition to TADS, Dr. Robb in her talk will review the results of other important trials in the field of pediatric mood disorders, including those from industry and other NIH-supported studies: Treatment of Resistant Depression in Adolescents (TORDIA), Treatment of Early-Age Mania (TEAM), and the Collaborative Lithium Trials (CoLT).

As Teen Marijuana Use Increases, So Does Risk of Psychotic-Like Experiences

Dr. Robb’s session also will touch on the US Food and Drug Administration (FDA) Black Box Warning that antidepressants increase suicidality risk, which actually may have the opposite effect as intended. She said the rates of suicide for people under age 19 had steadily dropped from 1990 to 2003. After the warning, though, completed suicides have risen in this group.

“I think mental health professionals are reluctant to make the diagnosis and to prescribe the medication, and I think parents are afraid to pick up the medication and have their kids take it,” she said. “Untreated depression is associated with suicide.”

While Dr. Robb acknowledged it will be a tough battle to get the FDA to remove the Black Box Warning (the agency has removed other Black Box Warnings, but rarely does so), she does hope the government will continue to fund trials on pharmacotherapy in children and adolescents, which has slowed considerably over the past decade.

“As someone who has dedicated my life to taking care of kids with mental illness, I would like to see more federal as well as industry dollars directed toward active treatment and intervention at a younger age so these patients can become productive members of society,” she said. “A depressed or manic kid can experience academic and social difficulties. All you have to do is look at the rising tide of suicides in children and adolescents to know it is a serious problem. And it needs early recognition and treatment rather than delay.”

—Mike Bederka