Objective: Presence of psychotic symptoms seems to be a commonplace in early-onset bipolar disorder (BD). However, few studies have examined their occurrence in adolescent-onset BD. We sought to investigate the frequency of affective and psychotic symptoms observed during the first manic episode in adolescents. Methods: Forty-nine adolescents with bipolar I disorder (DSM-IV criteria) were admitted to a psychiatric hospital during their first acute manic episode. Assessment for current psychiatric diagnosis was performed by direct clinical interview and the DSM-IV version of the Diagnostic Interview for Children and Adolescents (DICA). Results: Teenage inpatients with BD consistently exhibited typical manic features, such as euphoria, grandiosity, and psychomotor agitation. In addition, disorganization and psychotic symptoms were present in 82 and 55% of the total sample, respectively. There was no significant difference in symptoms between early- and late-adolescent subgroups. Remarkably, most patients (76%) reported previous depressive episode(s); of these, 47% had prominent psychotic features in the prior depressive period. Conclusion: These findings suggest that disorganization and psychotic symptoms during the first manic episode are salient features in adolescent-onset BD, and that psychotic depression frequently may precede psychotic mania. Nevertheless, differential diagnosis with schizophrenia should be routinely ruled out in cases of early-onset first psychotic episode.

Resumo Introdução: Distúrbios do ritmo circadiano têm sido relatados em estudos com crianças e adolescentes deprimidos. O objetivo deste estudo foi avaliar se existe relação entre a potência espectral de 24 horas do ritmo de atividade e repouso e sintomas clínicos de depressão em adolescentes. Métodos: Seis adolescentes com idade entre 14 e 17 anos foram recrutados para o estudo. Eles foram diagnosticados com depressão maior de acordo com os critérios do Manual Diagnóstico e Estatístico de Transtornos Mentais, 4ª edição (DSM-IV), identificados utilizando-se o instrumento Schedule for Affective Disorders and Schizophrenia for School Aged Children: Present and Lifetime Version (K-SADS-PL). Os sintomas depressivos foram avaliados pelo questionário Children's Depression Rating Scale - Revised (CDRS-R) e por avaliações clínicas. A atividade motora foi monitorada por um período de 13 semanas consecutivas e registrada a cada 10 minutos utilizando-se monitores de atividades usados no pulso. Todos os pacientes utilizaram o antidepressivo sertralina começando após a primeira semana até o final do estudo. Resultados: Foi observada uma relação entre escores altos no CDRS-R e valores baixos de potência espectral de 24 horas no ritmo de atividade e repouso. Conclusão: A potência espectral de 24 horas do ritmo de atividade e repouso apresentou uma correlação significativa (negativa) com os sintomas clínicos de depressão.

Abstract Introduction: Disorders of circadian rhythms have been reported in studies of both depressed children and of depressed adolescents. The aim of this study was to evaluate whether there is a relationship between the 24-hour spectral power (24h SP) of the activity/rest rhythm and the clinical course of depression in adolescents. Methods: Six 14 to 17-year-old adolescents were recruited for the study. They were all suffering from major depressive disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria, as identified by the Schedule for Affective Disorders and Schizophrenia for School Aged Children: Present and Lifetime Version (K-SADS-PL). Depressive symptoms were assessed using the Children's Depression Rating Scale - Revised (CDRS-R) and clinical evaluations. Locomotor activity was monitored over a period of 13 consecutive weeks. Activity was measured for 10-minute periods using wrist-worn activity monitors. All patients were prescribed sertraline from after the first week up until the end of the study. Results: We found a relationship between high CDRS values and low 24-hour spectral power. Conclusions: The 24h SP of the activity/rest rhythm correlated significantly (negatively) with the clinical ratings of depression.

Abstract Background Thought and language disorders are main features of adults with schizophrenia and bipolar disorders however studies on such abnormalities are scant in young patients with very early onset psychosis (VEOS). The aim of the present study is to assess the relationship between language and thought disorders in patients with very early onset schizophrenia (SCZ), schizoaffective disorders (SCA) and bipolar disorders (BD). Method Forty-one patients (18 SCZ, 16 BD, and 7 SCA) with mean age less than 15 years old were assessed through a series of neurocognitive and psycholinguistic tests, including the Thought, Language and Communication Scale (TLC). Results SCZ group performed worse in all tests as well as the TLC, followed by SCA and BD groups respectively. Thought disorders were related to deficits in executive functioning and semantic processing, and the metaphors’ test was the best predictor of TLC functioning. Discussion TD in SCZ, SCA and BD are one of the most important features in patients with VEOS and that the evaluation of metaphor comprehension can be an important instrument in the early detection of this disorder.

OBJETIVO: Comparar as características clínicas de transtorno depressivo maior entre crianças e adolescentes. MÉTODO: Amostra constituída de 58 sujeitos admitidos consecutivamente em um serviço especializado em transtornos do humor na infância e adolescência durante um período de 6 meses. Foram considerados crianças sujeitos com idade entre 5 e 9 anos, e adolescentes aqueles com idade entre 10 e 17 anos. Todos os participantes preenchiam diagnóstico de transtorno depressivo maior seguindo os critérios de DSM-IV. O diagnóstico de transtorno depressivo maior e avaliação de aspectos psicopatológicos foram realizados por entrevista clínica direta e aplicação de entrevista de apoio ao diagnóstico. O funcionamento global e a gravidade dos sintomas depressivos foram mensurados através de versões adaptadas de Children’s Depression Rating Scale-Revised Version e Children Global Assessment Scale. RESULTADOS: Os sintomas depressivos mais freqüentes foram: anedonia (72,4%), humor depressivo (72,4%), diminuição de concentração (62,1%) e irritabilidade (58,6%). A intensidade do episódio depressivo dessa amostra variou de leve a moderada. Cinqüenta por cento relataram pensamentos mórbidos e 29,3% apresentaram sintomas psicóticos variados. Quando comparados com crianças, adolescentes apresentaram significativamente mais humor depressivo (p = 0,043), baixa auto-estima (p = 0,002) e mais dificuldade de concentração (p = 0,020). As adolescentes femininas tinham mais baixa auto-estima (p = 0,003) e os masculinos mostraram mais diminuição de concentração (p = 0,016). CONCLUSÃO: Esse estudo sugere que idade e gênero poderiam influenciar na apresentação clínica de transtorno depressivo maior em crianças e adolescentes. Estudos com amostra mais representativa serão necessários.

OBJECTIVE: To compare clinical characteristics of major depressive disorder symptoms between children and adolescents. METHOD: The subjects were 58 patients of a Child and Adolescent Affective Disorder Clinic consecutively admitted during a six-month period. Children aged 5-9 years old and adolescents from 10-17 years old currently meeting DSM-IV criteria diagnosis of major depressive disorder were chosen. Current MDD diagnosis and depressive psychopathology were assessed by a clinical interview and the Diagnostic Interview for Children and Adolescents-DSM-IV version. The Children’s Depression Rating Scale-Revised Version and the Children Global Assessment Scale rated the severity and global functioning of major depressive disorder. RESULTS: The most common depressive symptoms were: anhedonia (72.4%), depressed mood (72.4%), decreased concentration (62.1%), and irritability (58.6%). The intensity of depressive episodes of this sample ranged from mild to moderate. Fifty percent reported thoughts of death, and 29.3% presented a variety of psychotic symptoms. When compared with children, adolescents reported a significantly more depressed mood (p = 0.043), lower self-esteem (p = 0.002), and had more difficulty concentrating (p = 0.020). Female adolescents had lower self-esteem (p = 0.003), and male adolescents showed more decreased concentration (p = 0.016). CONCLUSION: This study suggests that age and gender differences might influence the clinical presentation of major depressive disorder in children and adolescents. Further studies with larger samples are needed.

O transtorno do humor bipolar de início na infância e adolescência tornou-se um grande desafio aos profissionais que atendem a essa população, bem como a quem se dedica a estudá-la com mais profundidade. Primeiramente, isso se deve à dificuldade em se fechar o diagnóstico clínico e também em se estabelecer uma terapêutica medicamentosa eficaz, segura e permanente. Diferenças no padrão de ciclagem, predominância de fases mistas, gravidade das crises e a necessidade de se utilizar associações farmacológicas tornam o tratamento do transtorno bipolar de início precoce bastante complexo, exigindo uma gama maior de possibilidades terapêuticas. O caso apresentado relata a experiência com o uso da quetiapina em um paciente com o diagnóstico clínico de transtorno do humor bipolar de início na infância e adolescência, que começou aos 12 anos, e cuja resposta aos diferentes esquemas se mostrou insatisfatória. O uso da quetiapina mostrou-se eficaz no controle da crise e na estabilização do humor neste caso.

Bipolar disorder in children and adolescents has become a great challenge for professionals who work with this type of patients, as well as for researchers interested in studying it in depth. Firstly, diagnostic assessment is difficult; secondly, to establish a safe, long-term and effective treatment is challenging. Different cycling patterns, predominance of mixed episodes, severity of symptoms and need of polypharmacy makes the treatment of child and adolescent bipolar disorder very complex and requiring a wider range of therapeutic resources. The present case reports a successful use of quetiapine for a bipolar adolescent diagnosed at the age of 12 years who had been unsuccessfully treated using many therapeutic options. Quetiapine showed efficacy in both acute and prophylactic treatment of early-onset bipolar disorder.

Os conhecimentos sobre transtorno afetivo bipolar com início na infância e na adolescência têm avançado muito nos últimos 15 anos. Atualmente, os esforços estão dirigidos para investigar o quadro clínico, para o desenvolvimento de instrumentos que auxiliam diagnóstico precoce e investigações de melhores formas de tratamentos de crianças e adolescentes portadores do transtorno. O presente texto tem objetivo de apresentar as principais características clínicas do transtorno em crianças e adolescentes, assim como as denominações, as descrições de tipos clínicos e do padrão de ciclagem mais comum da doença em jovens. Discussões sobre comorbidades, diagnóstico diferencial e avanço em tratamento farmacológico também serão apresentados.

Many advances in the knowledge of childhood- and adolescent-onset bipolar disorder have been seen over the last 15 years. Current efforts focus on investigating clinical features, developing more instruments for early diagnosis and improving treatment research. The present study aims to present the main clinical characteristic of the disorder in children and adolescents, as well as the nomenclature, description of clinical phenotypes and the most common cycling pattern in youths. A discussion of comorbidity, differential diagnosis and advances in psychopharmacological treatment will also be presented.