Dr. Whiteside compared bipolar disorder to ADHD to help clinicians appreciate how to best understand it. Key differences with ADHD are an earlier age of onset, a more consistent presence of symptoms without episodes, a need for sleep despite possible insomnia, and only situational depression. In a 1998 study, a comparison of bipolar I and ADHD revealed that 89% of bipolar children had an elevated mood, compared with just 14% of those with ADHD. A similar gulf existed with grandiose thoughts, occurring in 86% of children with bipolar disorder and 5% of those with ADHD. Likewise, a much greater proportion of children with bipolar disorder experienced “flights of ideas,” decreased sleep, or hypersexuality, compared with these symptoms in children with ADHD.
Treating depression: Behavioral interventions
Psychopharmacology can be beneficial, but it works best when combined with behavioral interventions and simply explaining the disorder, said Dr. Whiteside. “There’s a lot of evidence that exercise can be a powerful treatment with depression,” he said. “Education is especially important since one of the four features of depression is a sense of hopelessness and belief that nothing is going to [get] better, so for them to know there are steps they can take is a very powerful intervention itself.”
The most effective intervention, however, is cognitive-behavioral therapy, with an 81% success rate 1 year out and a 98% success rate 2 years out. After the initial intervention, however, the numbers are more modest, with 67% of children no longer meeting major depressive disorder criteria when undergoing cognitive-behavioral therapy, compared with 48% in the waiting-list control group.
An important aspect to education starts with developing an alliance with a family so that the clinician can explain the condition and its treatment, build trust, and instill hope. In doing so, both parents’ and children’s expectations can be adjusted so that children feel less guilty and parents respond less negatively to their children.
Treatment with medication
Although only fluoxetine and escitalopram have Food and Drug Administration approval for MDD, Dr. Huxsahl recommended starting kids with mixed anxiety and depression on fluoxetine, fluvoxamine, or sertraline, and suggested clinicians not shy away from the target doses recommended for each drug. After 2-4 months of acute treatment, clinicians also should help families understand that continuing the treatment for at least 4-9 months and then potentially taking a maintenance dose for up to 3 years may be recommended.
“I would encourage you to educate the parents, and especially the teenagers, that they need to take the medication beyond the time that they are depressed,” he explained. Initially, however, start with a low dose and then increase it within 4 weeks if no response occurs. After 8 weeks, switch agents if no response has occurred, a process that requires monthly visits for the first 3-6 months of treatment.
Another question families and clinicians face is when to taper off medication when moving to a maintenance dose or working toward no longer taking the medication.
“In at least one study where they randomized kids to tapering during the school year or in the summer, the findings showed that the kids actually did better in the summer,” said Dr. Huxsahl. But follow-up is important during cessation because during the first 2-3 months is when there is the greatest risk for relapse or recurrence.
Dr. Whiteside and Dr. Huxsahl said they had no relevant financial disclosures.