Mood disorders in childhood and adolescence

Rocha, Thiago Botter Maio; Zeni, Cristian Patrick; Caetano, Sheila Cavalcante; Kieling, Christian

doi:10.1590/1516-4446-2013-S106

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Brazilian Journal of Psychiatry

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UPDATE ARTICLES • Rev. Bras. Psiquiatr. 35 (suppl 1) • 2013 • https://doi.org/10.1590/1516-4446-2013-S106 copy

Mood disorders in childhood and adolescence

Authorship SCIMAGO INSTITUTIONS RANKINGS

The identification and treatment of mood disorders in children and adolescents has grown over the last decades. Major depression is one of the most common and debilitating disorders worldwide, imposing a massive burden to the youth population. Bipolar disorder is being increasingly recognized as having its roots early in life, and its presentation during childhood and adolescence has been submitted to extensive research. This review aims to highlight clinical aspects of the current knowledge on mood disorders in the pediatric population, presenting updated information on epidemiology, diagnostic procedures, and management strategies. Limitations of available evidence and future directions of research in the field are also discussed.

Child; adolescent; bipolar; depression; mood

Medication	Dose	Side effects
Fluoxetine^* * FDA-approved for depression treatment in children and adolescents.	20 to 60 mg/day	Fluctuations in appetite, weight changes, nausea, diarrhea, constipation, dry mouth, insomnia, but also sedation, agitation, tremors, headache, dizziness, sweating, sexual side effects, vivid dreams, akathisia, disinhibition, bruising and rare bleeding, rare hyponatremia, rare hypotension.
Escitalopram^* * FDA-approved for depression treatment in children and adolescents.	10 to 30 mg/day
Citalopram	20 to 60 mg/day
Fluvoxamine	50 to 300 mg/day
Sertraline	50 to 200 mg/day
Venlafaxine	37.5 to 225 mg/day	Headache, nervousness, insomnia, sedation, nausea, diarrhea, decreased appetite, asthenia, sweating, SIADH, hyponatremia, dose-dependent increase in blood pressure.
Duloxetine	20 to 40 mg/day	Nausea, diarrhea, decreased appetite, dry mouth, constipation, insomnia, sedation, dizziness, sweating, increase in blood pressure (up to 2 mmHg), urinary retention.
Bupropion	3 to 6 mg/kg/day	Dry mouth, constipation, nausea, weight loss, anorexia, myalgia, insomnia, dizziness, headache, agitation, anxiety, tremor, abdominal pain, tinnitus, sweating, rash, hypertension, rare seizures.

Research center	Criteria adopted
Washington University School of Medicine⁵⁹59. Geller B, Bolhofner K, Craney JL, Williams M, DelBello MP, Gundersen K. Psychosocial functioning in a prepubertal and early adolescent bipolar disorder phenotype. J Am Acad Child Adolesc Psychiatry. 2000;39:1543-8.	- DSM-IV-TR + requirement of at least one cardinal manic symptom (elation and/or grandiosity); irritability is not considered alone due to its low specificity.- Episode: whole duration of illness; cycles: mood changes lasting a minimum of 4 hours.
Massachusetts General Hospital, Harvard Medical School⁴⁹49. Biederman J, Mick E, Faraone SV, Spencer T, Wilens TE, Wozniak J. Current concepts in the validity, diagnosis and treatment of paediatric bipolar disorder. Int J Neuropsychopharmacol. 2003;6:293-300.	- DSM-IV-TR.- When severe irritability is present, there is no need for change in the usual mood pattern.
University of Pittsburgh Medical Center⁴⁶46. Birmaher B, Axelson D, Strober M, Gill MK, Valeri S, Chiappetta L, et al. Clinical course of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry. 2006;63:175-83.	- BD-NOS definition: DSM-IV-TR modified in relation to the number of symptoms; if elation is present it is required more two symptoms of the DSM-IV-TR item B; and if irritability is present, three symptoms.- Duration of symptoms: at least 4 hours/day for 4 days (not necessarily consecutive days).
National Institute of Mental Health (NIMH)⁵⁸58. Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS. Defining clinical phenotypes of juvenile mania. Am J Psychiatry. 2003;160:430-7.	- Four different groups to cover the different presentations: - restricted phenotype (DSM-IV-TR), including cardinal symptoms and duration; - two intermediate phenotypes: one with hypomania or mania but without fulfilling the duration criteria (1 to 3 days), and the other without hypomania or mania, but irritability instead; - broad phenotype named severe mood dysregulation, chronic irritability, marked reactivity to negative stimuli; and hyperarousal, at least three times a week, for more than 1 year.

Medication	Dose	Side effects
Mood stabilizers
Lithium	10 to 30 mg/kg/day	Polyuria, polydipsia, diarrhea, nausea, weight gain, acne, hair loss, tremor, ataxia, thyroid and renal abnormalities (diabetes insipidus), cognitive deficits.
Divalproex sodium	15 to 60 mg/kg/day	Sedation, nausea, vomiting, weight gain, tremor, hair loss, thrombocytopenia, liver toxicity, pancreatitis, polycystic ovary syndrome, increase testosterone.
Carbamazepine	10 to 20 mg/kg/day	Sedation, nausea, vomiting, ataxia, dizziness, liver toxicity, Stevens-Johnson syndrome, spinal cord suppression, hyponatremia.
Oxcarbazepine	8 to 10 mg/kg/day	Drowsiness, nausea, vomiting, headache, dizziness, sedation, bone marrow suppression.
Lamotrigine	25 to 300 mg/day	Dizziness, tremor, drowsiness, nausea, headache, skin rash, Stevens-Johnson syndrome.
Topiramate	25 to 300 mg/day	Dizziness, sedation, psychomotor retardation, cognitive change.
Atypical antipsychotics
Risperidone	0.5 to 6 mg/day	Weight gain, sedation, increased salivation, gynecomastia, abdominal pain, nausea, hyperprolactinemia, dyslipidemia and diabetes mellitus.
Olanzapine	5 to 20 mg/day	Weight gain, dizziness, sedation, constipation, dry mouth, tachycardia, dyslipidemia and diabetes mellitus.
Quetiapine	25 to 600 mg/day	Drowsiness, sedation, dizziness, weight gain, dry mouth, constipation, tachycardia, dyslipidemia and diabetes mellitus.
Aripiprazole	2.5 to 45 mg/day	Drowsiness, nausea, vomiting, constipation, headache, dizziness.
Ziprasidone	40 to 160 mg/day	Activation symptoms, dizziness, sedation, nausea, dry mouth.

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[1] Correspondence: Christian Kieling, Department of Psychiatry, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350/400N, CEP 90350-009, Porto Alegre, RS, Brazil, E-mail: ckieling@ufrgs.br