Link: http://reference.medscape.com/viewarticle/840382?src=emed_case_nl_0&uac=20010AY&impID=634746

Medscape Case Challenge:

A Withdrawn 14-Year-Old Girl

Kirti Saxena, MD, Toi Blakley Harris, MD, Angelo P. Giardino, MD, PhD

February 26, 2015

Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions.

Background

A 14-year-old girl in the fourth month of her freshman year of high school lives in a two-parent household with a younger brother and has a relatively large extended family that lives close by. In middle school, she was described by teachers as "fretful." She worried a great deal about getting assignments in on time and would occasionally voice concerns about the health and well-being of her older relatives.

At the start of high school, she maintained good grades, tried out for the track and field team, and developed several close friendships. However, not long after the first days of sophomore year, she lost interest in school, had trouble sleeping, lost her appetite, and quit the track team. Her friends report that she is not communicating much. Her teachers describe missed assignments, and her parents state that she stays in her bedroom after school and for most the weekend. When her parents ask her about her behavior, she reportedly responds that "it's nothing" or that they should "just leave her alone."

Physical Examination and Work-up

The patient was initially taken to her primary care provider (PCP), who conducted a complete physical examination, including blood tests, that ruled out anemia and thyroid problems. With permission, the PCP obtained blood and urine drug screenings and a pregnancy test. All laboratory data were within normal limits, and the PCP made a referral to psychiatrist.

During the consultation, the psychiatrist found the patient to be sullen, alert, and oriented to all domains and coherent in her thinking. She did not disclose any thoughts of suicide. Her memory (both short and long term) was intact.

She denied any traumatic events or recent losses. When asked about her recent decline in school performance and her departure from the track and field team, she reports that she simply lost interest and is unable to concentrate on her studies. She became tearful when describing how her behavior was "disappointing her family." She explained that she just wants to stay in bed in her room because she is so tired that she does not have the energy to worry about things or get a good night's sleep.

On the basis of the history, physical examination, and work-up, what is the diagnosis?

Anxiety

Attention-deficit/hyperactivity disorder

Major depressive disorder (MDD)

Conduct disorder

Discussion

The patient appears to be suffering from more than adolescent moodiness. On the basis of the diagnostic criteria described in detail below, she can be diagnosed with MDD, which is among the more common psychiatric conditions diagnosed in adolescence.

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), uses the same basic criteria to diagnose depression in children and adolescents as in adults.^[1] A few adjustments to the diagnostic criteria are made to account for the differences in age and stage of development in adults vs children. In this case, the patient meets the criteria for MDD, commonly referred to simply as "depression."

The DSM-IV-TR classified depression into MDD, dysthymic disorder, other specified depressive disorder, and unspecified depressive disorder.^[1] Although the criteria for depressive disorders are similar in adults and younger individuals, children and adolescents may present with irritable mood as the prominent mood symptom (with or without depressed mood).

According to the DSM-5, a child or adolescent meets the diagnostic criteria for MDD when a minimum of five of the following nine symptoms are present during the same 2-week period:

·         Depressed mood or irritable mood, or loss of interest or pleasure;

·         Markedly diminished interest or pleasure in activities;

·         Decrease or increase in appetite;

·         Insomnia or hypersomnia;

·         Psychomotor agitation or retardation;

·         Fatigue or loss of energy;

·         Feelings of worthlessness, diminished ability to concentrate;

·         Recurrent thoughts of death; and

·         Recurrent suicidal ideation, without a specific plan for committing suicide.

At least one of the symptoms must be either depressed/irritable mood or loss of interest or pleasure. The symptoms must represent a change from previous functioning and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The patient in this case has more than five of the above symptoms and has experienced them for several months, meeting the diagnostic criteria for MDD.

MDD can further be broken down into subtypes, including atypical, psychotic, seasonal, catatonic, melancholic, and postpartum depression. Atypical features include an increase in appetite or significant weight gain, increased sleep, feelings of heaviness in the arms or legs, and rejection sensitivity.^[2]

Psychotic depression, although rare before adolescence, represents a severe form of depression, with psychotic symptoms usually presenting as mood congruent. Children primarily have auditory hallucinations, whereas adolescents usually have delusions. Adolescents with psychotic depression tend to do worse, and some later develop bipolar affective disorder.^[3]

Youth whose symptoms of depression predominantly occur during winter or fall (the season when there is less daylight) are considered to have seasonal affective disorder (SAD). Because school starts in the fall or winter months, distinguishing depression triggered by school stress from SAD is important.^[3]

Approximately 20% of youth with MDD experience manic episodes by adulthood.^[4] Indeed, depression is usually the first symptom of bipolar disorder recognized in children and adolescents. Factors predicting development of mania in depressed youth include a family history of bipolar disorder, a depressive episode characterized by rapid onset, psychomotor retardation, and psychotic features.^[3]

The DSM-5 criteria for dysthymia include a depressed or irritable mood for at least 1 year. While the patient is depressed or irritable, at least two of the following must be present:

·         Decreased or increased appetite;

·         Insomnia or hypersomnia;

·         Low energy or fatigue;

·         Low self-esteem;

·         Poor concentration; or

·         Feelings of hopelessness.

In addition, symptoms must not resolve for more than 2 months at a time. For both MDD and dysthymia, the symptoms should not be due to substance abuse, use of medications, other psychiatric illness, bereavement, or medical illness.

"Other specified depressive disorders" involve presentations in which symptoms are characteristic of a depressive disorder and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning but do not meet the full criteria for any of the depressive disorders in that diagnostic class.

Examples of presentations that can be specified using the "other specified" designation include the following:

·         Recurrent brief depression: This requires concurrent presence of depressed mood and at least four other symptoms of depression for 2-13 days at least once per month (not associated with the menstrual cycle) for at least 12 consecutive months in an individual whose presentation has never met the criteria for any other depressive or bipolar disorder and does not currently meet active or residual criteria for any psychotic disorder.

·         Short-duration depressive episode (4-13 days): This involves depressed affect and at least four of the other eight symptoms of a major depressive episode associated with clinically significant distress or impairment that persists for more than 4 days but less than 14 days. The individual's presentation has never met criteria for any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic disorder, and does not meet criteria for recurrent brief depression.

·         Depressive episode with insufficient symptoms: This requires depressed affect and at least one of the other eight symptoms of a major depressive episode associated with clinically significant distress or impairment that persist for at least 2 weeks. The individual's presentation has never met criteria for any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic disorder, and does not meet criteria for mixed anxiety and depressive disorder symptoms.

"Unspecified depressive disorder" is a category that applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class. The unspecified depressive disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific depressive disorder and includes presentations for which information is insufficient to make a more specific diagnosis (eg, in emergency department settings).

Depressive disorder with anxious distress is noted when at least two of the following symptoms are present during most days of a major depressive episode or persistent depressive disorder (dysthymia):

·         Feeling keyed up or tense;

·         Feeling unusually restless;

·         Difficulty concentrating because of worry;

·         Fear that something awful may happen; or

·         Feeling that the individual might lose control of himself or herself.

In addition, depressive disorder with anxious distress can be subcategorized by severity on the basis of how many of the above symptoms are present. Current severity is as follows:

·         Mild: two symptoms;

·         Moderate; three symptoms;

·         Moderate to severe: four or five symptoms; and

·         Severe: four or five symptoms, with motor agitation.

Anxious distress has been noted as a prominent feature of both bipolar disorder and MDD in primary care and specialty mental health settings. High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse. As a result, accurately specifying the presence and severity of anxious distress is important, for treatment planning and monitoring of response to treatment.

Depressive disorder with mixed features is diagnosed when the following manic/hypomanic symptoms are present nearly every day during most days of a major depressive episode:

·         Elevated expansive mood;

·         Inflated self-esteem or grandiosity, more talkative than usual or pressure to keep talking; and

·         Flight of ideas, or the subjective experience that thoughts are racing

The choice of initial acute therapy for MDD depends on the following factors:

·         Severity;

·         Number of prior episodes;

·         Chronicity;

·         Subtype;

·         Patient age;

·         Contextual issues (ie, family conflict, academic problems, exposure to negative life events);

·         Ability to adhere to treatment recommendations;

·         Previous response to treatment; and

·         Patient's and family's motivation for treatment.

In mild cases, psychosocial interventions and psychotherapies are often recommended as first-line treatments, whereas in the most severe cases, medication in addition to psychotherapeutic intervention is often recommended.

Cognitive-behavioral therapy (CBT) has been shown in multiple randomized clinical trials to be effective in the treatment of mild MDD in children and adolescents. For moderate-to-severe depression, psychotherapies and psychopharmacologic treatment are recommended. Hospitalization should be considered for severely depressed persons.

In CBT for MDD or dysthymia, the focus is on cognitive distortions. These include negative distortions of life experience and a negative view of the self and outside world. CBT teaches new ways of thinking to replace negative thoughts. The therapist is an active participant, and the focus is on the child. CBT often involves keeping a diary and doing homework. The goals are to alleviate the depressive episodes; to prevent recurrences by identifying and testing negative cognitions; and to develop flexible, positive ways of thinking.

Factors that appear to be related to the response to psychotherapy include the following:

·         Age at onset of depression;

·         Severity of depression;

·         Presence of comorbid psychiatric disorders;

·         Presence or absence of social support;

·         Parental psychopathology;

·         Family conflict;

·         Exposure to stressful life events;

·         Socioeconomic status;

·         Quality of treatment;

·         Therapist's expertise; and

·         Motivation of the patient and therapist.

Studies on pharmacotherapy in youth with MDD are few. Agents that have been used or proposed for use include the following:

·         Tricyclic antidepressants;

·         Selective serotonin reuptake inhibitors; and

·         Other antidepressants: heterocyclics (eg, amoxapine and maprotiline), monoamine oxidase inhibitors, bupropion, venlafaxine, and nefazodone (found useful in adults).

Mood disorders, such as depression, substantially increase the risk for suicide; suicidal behavior is a matter of serious concern for clinicians who deal with the mental health problems of children and adolescents. The incidence of suicide attempts reaches a peak during the mid-adolescent years, and the mortality rate from suicide increases steadily through the teenage years; suicide is the third leading cause of death in that age group.

The US prevalence rates for depression in children and adolescents vary. Studies have demonstrated that depression is not rare and is regularly encountered in pediatric and psychiatric practice. Birmaher and colleagues^[5] found the incidence of depression to be approximately 2% in children and 4%-8% in adolescents.Garrison and colleagues^[6] conducted a study of adolescents aged 11-16 years in the southeastern United States and found that the 1-year incidence of major depression was 3.3%.

The World Health Organization report "Health for the World's Adolescents: A Second Chance in the Second Decade" states that depression is the most frequent cause worldwide of illness and disability in persons aged 10-19 years, with the highest rate in females. The report also states that up to one half of all mental disorders arise by age 14 years, but they are usually not recognized.^[7]

The presentation of some symptoms may change with age. Such symptoms as somatic complaints, irritability, and social withdrawal are more common in children, whereas psychomotor retardation, hypersomnia, and delusions are less common before puberty than they are in adolescence and adulthood.^[8-11]

The Substance Abuse and Mental Health Services Administration indicates that sex differences in depression rates emerge at age 12-17 years. Its report states that girls aged 12-17 years are three times more likely than boys aged 12-17 years to have had a major depressive episode in the past year.^[12]

Figure 1.

Figure 2.

Whether damaging experiences or biological processes trigger depressive episodes remains the topic of some debate. However, the final common pathways to depression involve biochemical changes in the brain. Sleep, appetite, and memory are commonly disturbed in persons with depression. Reductions in the activity of circuits that use serotonin and norepinephrine may contribute to depression; antidepressants act on one or both of these symptoms.

Neurotransmitter system abnormalities are being investigated to understand the biology of depression. Nobile and colleagues^[13] found that uptake of human platelet 5-hydroxytryptamine (5-HT) or serotonin, is differentially influenced in nondepressed and depressed children by a common genetic variant of the promoter region of 5-HT (Figures 1 and 2).

In summary, the patient's presentation and symptoms meet the diagnostic criteria for MDD. Although there are explicit diagnostic criteria for MDD, it may remain undiagnosed and therefore undertreated in adolescents. In this case, the patient's parents identified the problem early and have begun psychiatric care in a timely manner. The patient is likely to respond well to CBT and an initial course of medication.

For dysthymia to be diagnosed in children and adolescents, symptoms must be present for which of the following durations?

2 weeks

2 years

1 year

2 months

In a depressed youth, which of the following factors predict the development of mania?

Family history of bipolar disorder

Psychomotor retardation

Psychotic features

All of the above

References

1.      American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.

2.      Williamson DE, Birmaher, B, Brent DA, Balach L, Dahl RE, Ryan ND. Atypical symptoms of depression in a sample of depressed child and adolescent outpatients. J Am Acad Child Adolesc Psychiatry. 2000;39:1253-1259. [Medline]

3.      Birmaher B, Brent D; AACAP Work Group on Quality Issues, Bernet W, Bukstein O, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:1503-1526. [Medline]

4.      Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL. Bipolar disorder at prospective follow-up of adults who had prepubertal major depressive disorder. Am J Psychiatry. 2001;158:125-127. [Medline]

5.      Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J. Childhood and adolescent depression: a review of the past 10 years. Part II. J Am Acad Child Adolesc Psychiatry. 1996;35:1575-1583. [Medline]

6.      Garrison CZ, Waller JL, Cuffe SP, McKeown RE, Addy CL, Jackson KL. Incidence of major depressive disorder and dysthymia in young adolescents. J Am Acad Child Adolesc Psychiatry. 1997;36:458-465. [Medline]

7.      World Health Organization. Health for the world's adolescents a second chance in the second decade. http://apps.who.int/adolescent/second-decade/ Accessed January 20, 2015.

8.      Kovacs M, Gatsonis C. Secular trends in age at onset of major depressive disorder in a clinical sample of children. J Psychiatr Res. 1994;28:319-329. [Medline]

9.      Lewinsohn PM, Clarke GN, Seeley JR, Rohde P. Major depression in community adolescents: age at onset, episode duration, and time to recurrence. J Am Acad Child Adolesc Psychiatry. 1994;33:809-818. [Medline]

10.  Lewinsohn PM, Hops H, Roberts RE, Seeley JR, Andrews JA. Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. J Abnorm Psychol. 1993;102:133-144. [Medline]

11.  Lewinsohn PM, Rohde P, Klein DN, Seeley JR. Natural course of adolescent major depressive disorder: I. Continuity into young adulthood. J Am Acad Child Adolesc Psychiatry. 1999;38:56-63. [Medline]

12.  Substance Abuse and Mental Health Services Administration. Data spotlight. Depression triples between the ages of 12 and 15 among adolescent girls. http://www.samhsa.gov/newsroom/press-announcements/201207241200 Accessed October 15, 2012.

13.  Nobile M, Begni B, Giorda R, et al. Effects of serotonin transporter promoter genotype on platelet serotonin transporter functionality in depressed children and adolescents. J Am Acad Child Adolesc Psychiatry. 1999;38:1396-1402. [Medline]

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Cite this article: A Withdrawn 14-Year-Old Girl. Medscape. Feb 26, 2015.