Depression and Bipolar Disorder (Final)

Question 1

Core Features of Depression

Answer 1

Dysphoria: Feelings of prolonged sadness.
Irritability: Excessive sensitivity, hostility, and moodiness. Unique to children and adolescents.
Anhedonia: Loss of pleasure or interest in previously enjoyable activities.

Question 2

Major Depressive Disorder (MDD)

Answer 2

Defined by presence of a major depressive episode. Need 5 symptoms total (during the same two week period). Need at least one of the core features of depression: 1. Depressed mood, most of the day, nearly every day OR irritability (children and adolescents only), most of the day, nearly every day. 2. Anhedonia most of the day, nearly every day.
PLUS 4 of the following symptoms: weight change, insomnia, fatigue, psychomotor agitation, feelings of worthlessness, unable to concentrate or indecisiveness, recurrent thoughts of death.

Question 3

Specifiers for Depressive Disorders (apply across disorders not just MDD)

Answer 3

1. Anxious distress
2. Mixed features (some manic/hypomanic symptoms that don’t meet bipolar disorder threshold)
3. Melancholic features
4. Atypical features
5. With psychotic features - mood congruent or mood incongruent
6. With catatonia
7. Peripartum onset
8. Seasonal pattern
   *Anxious distress and atypical features are now the only specifiers relevant to persistent depressive disorder

Question 4

Persistent Depressive Disorder (PDD)

Answer 4

Depressed or irritable mood for most of the day, more days than not, as indicated by either subjective account or by observation by others. For kids, you only need to be at this level for one year. Also have to have two or more of the symptoms: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration, feelings of hopelessness. During the 1 year period, the person has never been without the symptoms for more than 2 months at a time.

Question 5

Disruptive Mood Dysregulation Disorder (DMDD)

Answer 5

Characterized by severe and recurrent temper outburst manifested verbally and/or behaviourally that are out of proportion. The timber outburst are inconsistent with developmental level. They occur three or more times per week. The mood between temper outbursts is persistently irritable or angry. Symptoms are present for 12 months or more. Not diagnosed before age 6 or after age 18. Age at onset of the outburst and irritable mood is before age 10. Child has never met criteria for a manic or hypomanic episode. DMDD is ODD (DMDD is more severe) or bipolar disorder.

Question 6

DMDD: Axelson et al. 2013

Answer 6

Examined DMDD in a large sample of 6- to 12-year-olds seeking psychiatric services. Found that DMDD was not well-differentiated from CD or ODD. No difference between youth with and without DMDD diagnosis in symptom severity or functional impairment. DMDD diagnosis showed poor stability.

Question 7

DMDD: Copeland et al. 2013

Answer 7

Examined the DMDD criteria in three large community samples. Three month prevalence rates for meeting criteria for disruptive mood dysregulation disorder ranged from 0.8% to 3.3% with the highest rate in preschoolers. Highest levels of co-occurrence were with depressive disorders and oppositional defiant disorder.

Question 8

Depression Diagnoses: Categorical vs dimensional

Answer 8

Many children and adolescents will have subclinical depression. They will not quite make diagnostic criteria, but they have a significant number of symptoms. Show significant impairment (e.g. academic, social). At greater risk for going on to develop depression as well as other disorders and difficulties (e.g. substance use). Just because you’re not meeting the full criteria doesn’t mean you’re not having impairment in certain parts of your life.

Question 9

Epidemiology of MDD: Lifetime Prevalence

Answer 9

1% of preschool-aged children (3- to 5-years-of-age). 2% of elementary school-aged children (5- to 12-years-of-age). 11% of adolescents (13- to 18-years-of-age). Prevalence increases across adolescence.

Question 10

An Aside on Preschool Depression

Answer 10

Earlier onset generally associated with higher risk for more severe & chronic of depression later on.

Question 11

An Aside on Preschool Depression: Luby et al (2014)

Answer 11

Study of around 250 preschoolers followed through school age. Preschool depression = 2.7x more likely to be depressed at school age. Also higher rates of anxiety and ADHD.

Question 12

An Aside on Preschool Depression: Gaffrey et al (2011)

Answer 12

2-week MDE duration criterion not as relevant for preschoolers. MDD in preschool associated with MDD 2 years later regardless of whether MDE duration criterion met at baseline if other symptoms were present.

Question 13

An Aside on Preschool Depression: Gaffrey at al (2013)

Answer 13

Depressed 4-6 year olds show altered brain activity (e.g., + amygdala activity) when viewing emotional faces vs non-depressed kids (also see this in adults).

Question 14

Epidemiology of MDD: Racial/ethnic differences

Answer 14

Tend to see slight differences, not huge. Latin youth more likely than White youth to meet diagnostic criteria for a mood disorder. Also other evidence than Black youth experience greater levels of mood disorders than White youth. White you more likely than both Latin and Black youth to have received treatment for a mood disorder. Usuals suspects for differences: overrepresentation in low SES groups, discrimination (interpersonal, systemic, cultural), etc.

Question 15

Epidemiology of MDD: Gender differences

Answer 15

Lack of differences in depression pre-puberty - become pronounced in adolescence. Girls become much more likely to have clinical levels of depression than boys throughout adolescence. No on explanation of why this happens.

Question 16

Epidemiology of MDD: Possible Explanations for Gender Gap

Answer 16

1. Girls are more likely to seek help
   –> NCS-A: No gender difference in use of services for depression.
   –> Gender difference found in community samples
   –> Not super conclusive
2. Biological factors
   –> Onset of elevated rates of depression in girls coincides with puberty.
   –> More mature pubertal status is linked to depression in girls, but not boys, and is a stronger predictor than age.
   –> Early onset puberty is a risk factor for depression.
   –> Puberty may sensitize girls to stress.
3. a) Stress
   –> Puberty may create stressors for girls (changes in physical appearance and sex-role identification)
   –> In general, robust link between stress and depression
4. b) Interpersonal Stress
   –> Conflict with friends, rejection by peers
   –> Girls are more likely to generate interpersonal stress than are boys
   –> Stronger association between interpersonal stress and depression for girls than for boys
   –> Girls are more invested in interpersonal relationships
5. Cognition
   –> Depression is associated with attributions about stressful life events that are likely to amplify negative affect.
   –> This cognitive bias appears comparable across girls and boys
6. Coping
   –> Girls are more likely to cope by ruminating, either alone or with a friend

Question 17

Biological Factors of Depression

Answer 17

Children of depressed parents are more likely to be depressed. Children with a parent who was depressed as a child are 14x more likely to become depressed before age 13. Why:
Heritability: Twin studies suggest heritability rates between 35% and 75%.
Stress reactivity: Early exposure to stress which may sensitize person to later stress.

Question 18

Stress Reactivity: Hypothalamic-Pituitary-Adrenal (HPA) axis

Answer 18

Hormonal response to stress, can measure it looking at cortisol.

Question 19

Stress Reactivity: Prenatal depression

Answer 19

Depression in moms associated with increased levels of cortisol: may affect fetus. Number of months a women is depressed during pregnancy predicts elevated levels of cortisol when children are 6-7 years of age. Elevated cortisol associated with internalizing problems.

Question 20

Stress Reactivity Postnatal (postpartum) depression

Answer 20

Biological: Potential exposure through breastmilk?
Behavioural: Infants develop rapidly, early experiences with caregivers may have profound influence. If you get sensitized to stress it impacts how you systems will respond to later stress. Maternal depression is associated with parenting behaviours that may be problematic for children’s development. Because infants can’t regulate their own stress they relay on their parents to Renault it for them - May contribute to dysregulation of stress responses.

Question 21

Social-Cognitive Processing

Answer 21

Studies that explicitly ask about interpretations of negative scenarios. Depression is associated with a tendency to select negative interpretations. Kids higher in depression tend to identity fewer assertive strategies.

Question 22

Assertiveness vs agressiveness

Answer 22

Assertiveness: Saying what you want
Aggressiveness: Getting what you want potentially at the cost of other people.

Question 23

Social-Cognitive Processing: Interpretation

Answer 23

Interpretation bias or response bias? - Just picking the most negative option available.
Interpretation that is accessible to verbal response: give the more negative interpretation when you are asked directly. Interpretation occurring outside of conscious awareness.

Question 24

Social-Cognitive Processing: Interpretation (Dearing & Gotlib, 2009)

Answer 24

Interested in whether daughters of mothers who had depression showed interpretation biases. Used two different interpretation tasks.
Task 1: Blend two words together acoustically. Neutral-negative (e.g. Cry-dry). Neutral-positive (e.g. Joy-boy). Result is an ambiguous word (should hear each 50/50 odds). At-risk girls showed preference for negative words if depression-related (not threat-related negative words like hate). Control showed preference for positive word in neutral-positive pairings.

Question 25

Social-Cognitive Processing: Response Search / Response Decision

Answer 25

Response Search: Generating possible behavioral responses to a social situation. The child retrieves from memory potential ways to respond to the perceived social cue or problem. Response Decision: Evaluating the potential responses and choosing one to act on. Report themselves less able to carry out assertive strategies. Evaluate avoidant strategies as more likely to result in positive outcomes and assertive strategies as less likely to result in positive outcomes.

Question 26

Interpersonal Theories of Depression

Answer 26

Behaviours: Less prosocial, less assertive, more avoidant and withdrawn, some children with depression are also more hostile and aggressive. Children and adolescents may be responding to challenging interpersonal situations in problematic ways (e.g., responding by aggressing or withdrawing when someone aggresses against you may result in continued experience of aggression, being treated poorly by peers results in increased depression).

Question 27

Stress Exposure vs. Stress Generation

Answer 27

Stress Exposure Models of Depression: Depression results from exposure to stressful events. This thing happens to me and it leads me to feel worse. Stress Generation Models: Depression may lead individuals to generate stressful life events. Difficulties in interactions may cause interpersonal problems.

Question 28

Stress Generation Models of Depression (Rudolph et al. 2000)

Answer 28

88 children who had been clinically referred. Using a clinical interview, placed participants into the following diagnostic groups: Depressed only, Externalizing only, Both (comorbid), Neither (clinical control). Assessed experience of life stress. Stressful episodes rated by researchers along several dimensions: Severity, extent to which child contributed to the event, interpersonal or non-interpersonal.

Question 29

Stress Generation Models of Depression (Rudolph et al. 2000): Results

Answer 29

Depression was associated with dependent, interpersonal stress (supports stress generation hypothesis). Depression was not associated with dependent, non interpersonal stress (externalizing disorders were). Depression was no associated with independent stressors (neither were externalizing disorders). Children with comorbidity experienced the highest levels of both interpersonal and non-interpersonal dependent stress.

Question 30

Stress Generation Models of Depression: Takeaway

Answer 30

Youth with more depression might be more likely to generate problematic interpersonal circumstances, or be involved in dependent interpersonal stress. These interpersonal circumstances, in turn, may exacerbate depression. See similar patterns for: Life hassles, victimization.

Question 31

Meta-analysis of stress-generation studies (Rnic et al., 2023)

Answer 31

95 longitudinal studies. Found good support for stress generation hypothesis. General trend line: the association between dependent interpersonal stressors and depression is stronger in kids than it is in older adults (saying that relative to later on, stress generation models matter even more in young kids than they do in adults). Overall psychopathology: dependent stress (Stressful events that are at least partially caused by the individual’s own actions, behaviors, or interpersonal style) is more predictive than independent stressors (Stressful events that are outside the individual’s control — not caused by their behavior). Stress exposure is also more important in early childhood.

Question 32

Interpersonal Theories of Depression - Friends

Answer 32

Friends are a critically important part of healthy development: Protect children from feelings of loneliness and depression, children with friendships are less likely to be victimized by peers, provides an opportunity to develop important social skills. May be more difficult to maintain healthy, close friendships in context of depression (friendships may also contribute to symptoms). Studies that have observed children with depression interacting with their friends have noticed the friends' affect becoming more negative over the course of the interaction.

Question 33

Co-rumination

Answer 33

Rumination is the tendency to dwell on problems and not solve them. Co-rumination is when two friends do it together (getting stuck on the problem). Paradox: Sharing and intimacy are associated with better friendships, but rumination and dwelling on bad things are associated with negative mood. Co-rumination at one time point predicts later increases in friendship quality and internalizing symptoms (Rose, 2002).

Question 34

Co-Rumination (Rose et al, 2014).

Answer 34

Dwelling on negative affect with a friend leads to depressive and anxious symptoms, but is not associated with friendship quality. In contrast, (a) discussing the problem repeatedly (rehashing), and (b) speculating about what might happen lead to increased friendship quality and closeness, but not associated with greater depressive or anxious symptoms. Moreover, you can talk about something a lot, but as long as you move on to talk about potential solutions it can be helpful and productive.

Question 35

Reassurance Seeking

Answer 35

Children want others to demonstrate that they care about them, tell them that they are okay, etc. For children higher in depressive symptoms, co-ruminance might only lead to a brief sense of relief. Initially, people will reassure. But the child will think that they don't mean it, and seeks more reassurance. Overtime, this becomes irritating and/or invalidating. Eventually, the child will be rejected. Reassurance seeking is associated with unstable friendships. i

Question 36

Contagion

Answer 36

Depressive symptoms of two friends might impact each other. If I have a friend who is more depressed right now, their depression predicts an increase in my depression over time.

Question 37

CBT Model of Depression

Answer 37

Understanding cognitive behavioural processes. Underlying diathesis-stress model: Personal diatheses Interact with stressful life events to disrupt normal mood. Depression maintained by negative cognitive and behavioural processes. Cognitive processes to target: Depressogenic thinking. Behavioural processes to target: Low reinforcement and negative life events, skill deficits.

Question 38

Emotional Spirals

Answer 38

Depression may begin, or deepen, as part of a downward emotional spiral: Negative events may breed negative moods... negative moods, negative behaviours... and negative behaviours, may produce negative thoughts and expectations for the future. But, moods do not have to just go down. We also have upward emotional spirals: Positive triggers can start a chain of pleasant feelings, events, and thoughts.

Question 39

Cognitive Techniques

Answer 39

Goal of CBT is not to convince the person that something bad is good. Rather it is to bring reaction in line with the event. Are there alternatives that might be more likely and make u not feel as bad about yourself?

Question 40

Cognitive Techniques in CBT

Answer 40

Goal is to help youths learn how to: Observe their thoughts, feelings, and behaviour. Consider alternative explanation. Solve problems and make rational decisions. Therapy as observation and experiment. Match developmental level: Use of concrete examples and cartoons.

Question 41

Behavioural Techniques in CBT

Answer 41

Keep track of mood and activity: How do you feel? What are you doing? Develop lists of rewarding activities: Activities that produce pride. Activities that produce pleasure. Change habits: Address environmental obstacles. Address skill deficits. Monitor impact and refine plan

Question 42

A meta-analysis on CBT efficacy in children & adolescents (Out et al., 2019)

Answer 42

31 CBT trials (4335 participants, all children and adolescents). Sub-clinical at baseline --> 63% lower risk depression @ follow-up. Clinical depression at baseline --> ~45% lower risk post-treatment. Predictors of positive outcomes: 1. Combination of behavioural activation + thought challenging 2. Involving parents in intervention.

Question 43

Meta-analysis CBT with adolescents in low and middle income countries (LMIC) (Davaasambuu et al., 2020)

Answer 43

28 studies total - different types of interventions. Micro-finance / economic interventions: If we give people that don't have access to resources more money, what odes that do for their depression. Interpersonal Therapy: A big predictor and maintenance factor of depression. Cat is similarly leading to a reduction in depression. Micro-finance / economic interventions: if you give people more money, kids will be less depressed (less of an effect than CBT). Interpersonal seems like it might working, but effect is closer to 0. Integrated therapies seem to also be working (not many studies done).

Question 44

Antidepressant Medication

Answer 44

Developmental differences: Many efficacious medications for adults, some do not work at all in children, most do not work as well in adolescents. May be due to difference in brain development or metabolism.

Question 45

Antidepressant Medications: Tricyclic antidepressants

Answer 45

Prevent the reuptake of norepinephrine and serotonin in the synapses or by increasing the responsiveness of receptors to these neurotransmitters. No evidence of efficacy in youth.

Question 46

Antidepressant Medications: Monoamine oxidase inhibitors (MAOIs)

Answer 46

MAO is an enzyme that breaks down some neurotransmitters. MAO inhibitors stop this enzyme thus increasing level of neurotransmitters in the synapse. Some mixed evidence of efficacy in teens. Potentially lethal side effects.

Question 47

Antidepressant Medications: Selective serotonin reuptake inhibitors (SSRIs)

Answer 47

Inhibit the reuptake of serotonin so that more is available in the synapse. Similar to tricyclics, but more specifically focused on serotonin. Good evidence for fluoxetine (Prozac) in teens. Tend not to be fatal in overdose. She effects: agitation, jitteriness, anger, hostility, nausea, stomach cramps.

Question 48

SNRI's

Answer 48

Like SSRIs, but also block norepinephrine. Used in depression and anxiety. Similar side effects to SSRIs.

Question 49

Antidepressants for Children and Adolescents

Answer 49

Some SSRI's show evidence of efficacy. Suggestion of increased risk of suicide, which led to black-box warning by the FDA: Appears on the package insert for medication. Warns of serious adverse side effects. Most serious warning the FDA gives.

Question 50

Black-Box Warning

Answer 50

Began with concern about specific drug Paxil. FDA wanted to get all the randomized controlled data involving antidepressants, and did find higher levels of suicide attempts in kids treated with anti-depressants than control trials. No deaths from suicides were observed in these trials. Similar findings in a follow-up study with more patients. But, other types of studies have shown that use of antidepressants is associated with decreased suicidality. Epidemiological data indicates that as use of antidepressants goes up, suicidality goes down.

Question 51

Antidepressants for Children and Adolescents: More Recent Studies (Gibbons et al. 2012)

Answer 51

Obtained complete longitudinal data from RCTs for Prozac from the drug companies and the Treatment for Adolescents wit Depression (TADS) study. Examined association between treatment group and clinical ratings of suicidal ideation. Did not find higher rates of suicidal ideation in youth treated with Prozac compared to placebo.

Question 52

Antidepressants for Children and Adolescents: More Recent Studies (Lu et al., 2014)

Answer 52

Investigated whether warnings and media coverage were associated with decreased use of anti-depressants and increased suicides. Before the media coverage, antidepressant use was increasing, and when the warnings cam out the increase went down. But post black-box warning trend, attempt of psychotropic drug poisonings went up (use went down but attempts went up). Young adults showed same pattern as younger kids. Adults also saw a decrease in use after black-box label warnings, but no change in attempted suicides or completed suicides.

Question 53

Treating Depression in Preschoolers

Answer 53

Diagnosis of depression in preschoolers is very new. Not much is known about the effective treatments. Rare for preschoolers to take anything, and if they were it would likely be a stimulant for something like ADHD. Therapy recommended as the first approach.

Question 54

Manic Episode

Answer 54

A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary). During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual, flight of ideas/racing thoughts, distractibility, increase in goal-directed activity, excessive involvement in pleasurable activities.

Question 55

Hypomanic Episode

Answer 55

Same as manic episode except: Lasting at least four consecutive days, represents a change in functioning for the person, but no marked impairment in social or occupational functioning.

Question 56

DSM Diagnoses - Bipolar 1

Answer 56

Manic episode. May or may not show depression. Specifier - with mixed features.

Question 57

DSM Diagnoses - Bipolar 2

Answer 57

Major depressive episodes and hypomanic episodes. Has not ever had a full manic episode (Specifier - with mixed features.

Question 58

DSM Diagnoses - Cyclothymia

Answer 58

Period lasting at least 1 year (in children and adolescents, 2 years for adults) when there are numerous hypomanic and depressive symptoms that do not meet full criteria for either a hypomanic, manic, or major depressive episode.

Question 59

Bipolar Disorder in Children

Answer 59

Between 1990 and 2000 diagnoses of bipolar disorder in children quadrupled. Became a big public health concern. 1999 saw the publication of a book entitled the Bipolar Child by a New York psychiatrist, who argued that bipolar disorder in children was overlooked. He provided a vague and general list of behaviours.

Question 60

Bipolar Definition

Answer 60

In 2001, the field decided that bipolar disorder could be diagnosed in children. Noted that there can be differences in presentation of bipolar in children and adults. Adults typically have discrete episodes. In children, may see changes in mood even within the same day (because of these quick fluctuations, they tend to be around for a long time).

Question 61

Bipolar Disorder: Narrow phenotype

Answer 61

"Classic" adult symptoms without any alterations. Many, grandiosity. Some children/adolescents meet the full diagnostic criteria meant for adults.

Question 61

Bipolar Disorder: Broader phenotype

Answer 61

Irritability, mood lability. Irritability is much more common than mania. However, irritability is not a specific symptom for bipolar (it's also seen in many other disorders - is this actually bipolar disorder?).

Question 62

Bipolar Disorder - Diagnostic Challenges

Answer 62

Irritability, rather than euphoria, can be the predominant mood state: Differential diagnosis (Depression, ODD, CD, ADHD). Due to this overlap, some authors have argued that to be diagnosed with bipolar disorder, children must show core features of mania, which has higher specificity (grandiosity, elevated mood). These features do occur in a significant number of youth who have been identified as having bipolar disorder.

Question 63

Bipolar Disorder Definition: Practice Parameters of the American Academy of Child and Adolescent Psychiatry

Answer 63

They support a more narrow phenotype saying that adult criteria should be applied to kids. Mania, which may include irritability, present as a marked change in the individual's state. Diagnostic validity of bipolar disorder in preschool children has yet to be firmly established.

Question 64

Bipolar Disorder Definition: DSM5

Answer 64

Concerns about over-diagnosing bipolar disorder in childhood. Frequent severe tantrums and chronic irritability. Symptoms are not specific to bipolar disorder. All this led to DMDD previously talked about.

Question 65

Pediatric bipolar Disorder: Prevalence & Course

Answer 65

Bipolar disorder very rare prior to puberty. Rates rises in adolescence. NCS-A estimates lifetime prevalence of Bipolar I/Bipolar II at 2.9%. About 60% of people with bipolar disorder experience their first episode in adolescence (i.e. prior to 19-years of age). Mania in adolescence is associated with psychosis, mixed episodes (mania/depression), extreme mood lability.

Question 66

Course of Bipolar Disorder - Recovery

Answer 66

Recovery: 8 consecutive weeks in which an individual does not meet the DSM criteria for manic episode, hypomanic episode, depressive episode, or mixed episode. 40% to 100% of children and adolescents with bipolar disorder will recover within a year, but 60% to 70% of the children who recover will show recurrence within a year. Recovery rates differ based on age of onset.

Question 67

Bipolar Disorder - Comorbidity (ADHD & Disruptive behaviour disorders)

Answer 67

ADHD: 60% to 90% of children, 30% of adolescents with bipolar meet criteria for ADHD. Possible that stimulant medications may exacerbate bipolar symptoms. Disruptive behaviour disorders: 20% of children with bipolar disorder meet criteria for conduct disorder. Conduct symptoms may be a consequence of bipolar presentation.

Question 68

Bipolar Disorder - Clinical Correlates

Answer 68

Associated with marked social impairment: poor social skills, frequently teased and victimized, few friends, poor relationships with siblings, frequent hostility and conflict with parents.

Question 69

Etiology and Maintenance of Bipolar Disorder

Answer 69

Work with adults suggests that bipolar disorder is highly heritable. However, twin studies suggest that variability is not entirely due to genetics. Genetics appear to play a bigger role one early onset case. Multiple gene problems. Environmental factors likely play a role. Diathesis-stress model: High level of underlying genetic risk (diathesis) interacting with different contextual factors. Problematic family interactions (hostility, conflict). Contributes to expression of bipolar symptoms. Passive gene-environment correlation.

Question 70

Treatment of Paediatric Bipolar Disorder: Mood Stabilizers (Lithium)

Answer 70

Common treatment for adult bipolar disorder. Mood stabilizer. Approved for use in children aged 12 and older. Serious side effects. Compliance with instructions VERY important. Have to visit physician regularly to monitor side effects.

Question 71

Treatment of Paediatric Bipolar Disorder: Atypical Antipsychotics

Answer 71

Wide-ranging class of antipsychotics. Ten+ RCTs have demonstrated that these medications are effective for treatment of bipolar disorder in youth.

Question 72

Treatment of Paediatric Bipolar Disorder: Anti-Depressants

Answer 72

Depression can be chronic and severe. Mood stabilizer/antipsychotics may. not help that. Can that be treated with anti-depressant medication? Taking antidepressants if you have a bipolar disorder can lead to an increased risk for manic episodes. More likely to experience manic episodes than if treated with an atypical antipsychotic.

Question 73

Bipolar Disorder - Medication

Answer 73

Pharmacotherapy is indicated for nearly all youth with bipolar disorder. Many youth with bipolar will not receive medication. Many may be treated with the wrong medication (e.g. an antidepressant by itself).

Question 74

Recommendation for treating mani in youth is often as follows:

Answer 74

Begin with one atypical antipsychotic. If patient does not respond, or cannot tolerate the drug, taper, and then try a second atypical antipsychotic. If patient does not respond to two or three atypical antipsychotics, switch to lithium. If patient partly responded to antipsychotic, add lithium.

Question 75

Bipolar Disorder - Psychosocial Treatments

Answer 75

Medication is first line treatment. Family Education complements medication: Understanding disorder and symptoms. Reducing conflict in the family. Medication management.

Question 76

Evidence for Psychosocial Treatment - from Brickman et al. 2022 Annual Review

Answer 76

Well-established treatments = those focused on Family Psychoeducation & Skill Building (intended as add ons to medication). These include: Family-focused treatment for adolescents. Family-focused CBT. Psychoeducational psychotherapy. All family focused, CBT based, and intended as add-ons. Work to teach skills to increase # of positive family interactions - all very similar.

Question 77

Child and Family Focused CBT

Answer 77

RAINBOW acronym: Routine, Affect regulation, I can do it, No negative thoughts, Be a good friend and balanced lifestyle, Oh how can we solve this problem?, Ways to get support.

Question 78

CFF-CBT for Pediatric Bipolar Disorder

Answer 78

69 children diagnosed with bipolar disorder. Inclusion criteria: stabilization on medication (still symptomatic, but not in acute distress). Randomized to: Receive CFF-CBT (individual therapy), or TAU (assigned to a therapist in the same clinic). Outcome measures: Parent report of mani and depression, clinician report of depression. Results: Found that at post-treatment, youth in CBT group had lower mania symptoms than youth in control group. 88% of youth in CBT group were below the clinical cutoff for manic symptoms, at post-treatment, compared to 21% in the control group. Saw similar pattern for parent-reported depression. No difference for clinician-reported depression.