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Indian Pediatr 2012;49:
21-23 |
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Clinical Profile of Mood Disorders in Children |
Rajesh Sagar, Raman Deep Pattanayak and Manju Mehta
From the Department of Psychiatry, All India Institute of
Medical Sciences, Ansari Nagar, New Delhi, India.
Correspondence to: Dr Rajesh Sagar, Additional Professor,
Department of Psychiatry, All India Institute of Medical Sciences, Ansari
Nagar, New Delhi 110 029, India.
Email:
[email protected]
Received: October 10, 2010;
Initial review: November 13, 2010;
Accepted: January 15, 2011.
Published
online: 2011, May 30.
PII: S09747559INPE1000331-1
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Objective: To described the clinical profile of
pediatric mood disorders.
Design: Retrospective record review; Ages
≤16 y.
Setting: Tertiary case hospital.
Participants: Children ≤16
year with a DSM-IV diagnosis of Mood disorders.
Methods: Records were screened for the period
between June 1, 2008 and May 31, 2010.
Results: The prevalence of mood disorders was 4.1%
(38/930). Mood was depressed in 51.9% and irritable in 33.3% of depressive
disorders. Other common symptoms were anhedonia, sleep/appetite
disturbances, concentration difficulty and anxiety. Nearly 13.2% had
suicidal ideation and 28.5% had comorbid psychiatric disorder. Family
history was positive in 39.5%, while an identifiable stressor was present
in 50%.
Conclusions: The pediatric mood disorders have a
unique clinical presentation and requires more research, especially from
Indian setting.
Key words: Children, Depressive disorders, Early-onset, India,
Mood disorders, Pediatric.
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Over the past two decades, there is an increasing
recognition that children and adolescents can have mood disorders
beginning at a very young age [1]. The pediatric-onset disorders have a
potential to affect the cognitive, emotional and social development of the
child or adolescent and are a major source of morbidity and mortality
[2,3]. The early age of onset is usually associated with a severe or
recurrent disorder with significant academic and psychosocial impairment
[3]. Unfortunately, many of the children and adolescents with these
disorders remain undiagnosed and untreated [4].
The mood disorders broadly comprise of
depressive and bipolar disorders, which are currently diagnosed using
essentially the same criteria as in adults. Age-appropriate modifications
have been specified in DSM-IV [5]. However, research over past decade
indicates that there may be significant differences in terms of clinical
presentation among children and adults [3]. Pediatric-onset disorders may
even represent a special group of disorders with distinct phenomenology
and etiopathogenesis [6]. The study describes the clinical profile of
pediatric mood disorders presenting at a tertiary care hospital in India.
Methods
This study is a two year retrospective
review of clinical records of patients visiting our Child and Adolescent
Clinic, a specialty clinic with a team of psychiatrists, psychologists and
social workers-focusing on the mental health problems in children and
adolescents. Records were screened for the period between June 1, 2008 and
May 31, 2010. Patients aged 16 and below, belonging to either gender, who
had been diagnosed to be suffering from mood disorders as per DSM-IV [5]
were identified. Patients were excluded if psychiatric disorder was the
result of medical disorder or substance use or if there was inadequate
history or doubtful diagnosis. The relevant information was collected on a
semi-structured data sheet, which included the sociodemographic details
(age, gender, socioeconomic status, residence and education), risk factors
(birth and early developmental details, parental age at conception,
positive family history and psychosocial stressor, if any) and illness
details (onset, course, duration and symptomatology). Data was analyzed by
SPSS using descriptive statistics.
Results
A total of 930 patients were evaluated in child and
adolescent clinic over a period of two years, of which 38 patients (4.1%)
were identified to have Mood disorders. Depressive disorders (2.9%; n=27)
were twice as common as Bipolar disorders (1.2%; n=11).
The mean age of patients with mood disorders was
13.68±2.53 years (13.70±2.23 years for depressive disorders and 13.64±3.29
years for bipolar disorders). There were 60.5% (n=23) males with an
over-representation of males in depressive disorders (17:10). The mean
years of education was 7.71±2.62 and majority (84.2%; n=32)
belonged to middle socio-economic status families. Most (76.3%, n=29)
patients were from National Capital Region and rest were from neighboring
states of Uttar Pradesh, Bihar and Haryana. Patients were accompanied by
both parents (21.1%; n=8), either parent (68.4%, n=26), or a
sibling or an uncle (10.5%, n=4).
Nearly 42.2% of mood disorders had onset of mood
disorder in childhood (≤12yrs).
At the time of presentation, 7.4% of depressive disorders and 36.3% of
bipolar disorders had a prior history of mood episode(s). There was a
comorbid psychiatric disorder in 28.5% (n=11) of patients, in the
form of anxiety disorder (n=4), Attention deficit hyperactivity
disorder (n=3), conduct disorder (n=2) and dissociative
disorder (n=2).
A family history of psychiatric illness was present
among 39.5% (n=15) of mood disorders. An identifiable stressor with
a temporal relation to onset of illness was present in 50% (n=19)
of mood disorders. The common stressors were in the form of an Illness,
injury or death (n=7); interpersonal conflicts or scolding (n=5);
academic stressors (n=4); change of school/house (n=2) and
birth of a sibling (n=1). A history of perinatal complications was
present in 2.6%. The age of father at the time of conception was ≤35 years in 13.2% (n=5),
while the age of mother at the time of conception was ≤30 years in 26.3% (n=10).
Table I Clinical Symptomatology of Pediatric Mood
Disorders (N=930)
Depressive symptoms (Unipolar) |
Manic symptoms
(Bipolar) |
Depressed mood |
51.9% |
Mood disturbance |
100% |
Anhedonia |
51.9% |
Predominant cheerful |
50% |
Sleep/appetite disturbance |
48.1% |
Predominant irritable |
50% |
Decreased concentration |
40.7% |
Inflated self-esteem & grandiose ideas |
100% |
Anxiety symptoms |
37% |
Increase in goal directed activity |
87.5% |
Fatigue/weakness |
33.3% |
Overtalkativeness |
75% |
Decreased Interaction |
33.3% |
Decreased need to sleep |
62.5% |
Irritable mood |
33.3% |
Over demanding |
62.5% |
Hopelessness |
18.5% |
Distractibility |
37.5% |
Somatic symptoms |
18.5% |
Increased grooming |
25% |
Suicidal ideation |
11.1% |
Sexual disinhibition |
25% |
Psychotic symptoms (persecutorydelusion) |
11.1% |
Increased libido |
37.5% |
Guilt |
7.4% |
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Depersonalization |
3.7% |
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Obsessive compulsive symptoms |
3.7% |
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Catatonia |
3.7% |
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Discussion
In this study, the clinic prevalence for mood disorders
was 4.1%, earlier clinic-based epidemiological studies from India have
shown the prevalence of pediatric depressive disorders to vary between
1.2% and 5.9% [7]. The age of onset was ≤12 years in 42.2% of
patients, retrospective adult studies have also reported that 20% of
bipolar disorders may report the onset before ten years of age [8]. The
study findings also suggest a contribution of genetic vulnerability as
well as psychosocial stressors in onset of disorders, which is also
reported earlier [1,9].
Some differences have emerged in our sample compared to
the adult literature. Irritable, rather than euphoric or depressed mood,
was found in a significant proportion of mood disorder patients. In
previous studies, children with manic episode were found to have markedly
and chronically elevated levels of irritability rather than euphoria, but
some other researchers emphasize irritable mood to be significant only if
co-occuring with elated mood or grandiosity in diagnosis of mania [8].
Younger age of onset has previously been associated with more frequent
anxiety and somatic symptoms in depression [9,10]. In our study, anxiety
symptoms were quite common, present in 37% of depressed patients, while
somatic symptoms were not as frequent. The cognitive symptoms e.g.,
hopelessness and guilt were present less frequently in consonance with
previous literature [12], perhaps due to a less evolved cognitive
structure and relatively less capacity to articulate thoughts into words.
Decreased concentration emerged as a significant concern for many child
and adolescents patients, which also contributed to academic difficulties.
Suicidal ideation is common in early onset mood disorders [7,15] and was
manifested by 13.2% of sample, comprising of patients with unipolar and
bipolar depression.
The present study adds to the limited Indian literature
on pediatric mood disorders and describes their unique clinical
presentation. It is, however, limited by absence of a prospective design,
especially in view of issues concerning diagnostic stability. It is a
hospital based sample with limited generalizability to community patients.
There is also a need to study age-specific symptom manifestations in
children during early and middle adolescence. Larger studies with
prospective design are required to further elicit clinical and
phenomenological aspects of pediatric major psychiatric disorders.
Contributors: RS designed the study,
supervised the analysis, edited the final draft and will act as guarantor.
RDP participated in designing study, collected and analyzed the data and
wrote the initial draft of manuscript. MM participated in designing study,
supervised the analysis and editing of the final draft. All authors have
read and approved the final manuscript.
Funding: None; Competing interests: None
stated.
What This Study Adds?
• Pediatric mood disorders have a unique
clinical presentation. Both family history and psychosocial
stressors play an important role.
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