Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial

OBJECTIVE

To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression.

METHOD

After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores.

RESULTS

Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects.

CONCLUSIONS

Paroxetine is generally well tolerated and effective for major depression in adolescents.

Children's Interview for Psychiatric Syndromes (ChIPS)

OBJECTIVE

To describe the development and summarize the psychometric properties of the Children's Interview for Psychiatric Syndromes (ChIPS).

METHOD

ChIPS is a highly structured interview designed for use by trained lay interviewers in children aged 6-18 years. It screens for 20 Axis I disorders as well as psychosocial stressors. Questions use simple language and short sentence structure to enhance subject comprehension and cooperation. The interview is based on DSM-IV and results are presented in a concise, easy-to-interpret manner. There are both child and parent versions. The psychometric properties of each version were studied.

RESULTS

A series of 5 studies has demonstrated the validity of the DSM-III, DSM-III-R, and DSM-IV versions of the ChIPS as well as the validity of the P-ChIPS (parent version). Administration time is relatively brief, averaging 49 minutes for inpatients, 30 minutes for outpatients, and 21 minutes for a community-based sample.

CONCLUSIONS

ChIPS can be used as a screening instrument to maximize a clinician's efficiency, as a diagnostic instrument in clinical research, and as a training instrument to help mental health professionals learn psychiatric diagnosis. It can also be used in epidemiological research.

The Mania Rating Scale: can it be used in children? A preliminary report

The Mania Rating Scale (MRS) was evaluated for use in prepubertal children. Eleven manic and 11 matched controls with attention-deficit hyperactivity disorder were examined. MRS scores were significantly higher in manic versus ADHD children (p less than 0.0001), while scores on hyperactivity rating scales (Conners-Parent and Teacher Forms) did not differ between groups. Most individual MRS item scores differed significantly between groups (p less than 0.05). MRS scores correlated significantly with severity of mania (Clinical Global Impression--Mania, r = 0.84; p less than 0.0001). Age, race, and sex were not correlated with MRS scores. The MRS may be useful in differentiating mania from ADHD and determining the severity of mania in prepubertal children.

Depression in recently bereaved prepubertal children

OBJECTIVE

The purpose of this study was to ascertain depressive symptoms in recently bereaved prepubertal children and compare these symptoms with those of depressed prepubertal children.

METHOD

The subjects were 38 children who had recently experienced the death of one but not both of their parents. They had to meet strict inclusion criteria so that the effects of bereavement per se, rather than other significant stressors, could be assessed. The comparison group consisted of 38 hospitalized, depressed children individually matched to each bereaved subject for age, sex, and socioeconomic status. All of the children underwent systematic and comprehensive evaluation. They and their parents were independently evaluated by trained interviewers using the parent and child versions of the Diagnostic Interview for Children and Adolescents. Family histories and basic demographic information were also obtained.

RESULTS

The recently bereaved children endorsed many depressive symptoms. Thirty-seven percent of them met the DSM-III-R criteria for a major depressive episode. The depressed children, however, had more depressive symptoms on average than the bereaved children. The factors associated with increased depressive symptoms in the bereaved children were 1) the mother as the surviving parent, 2) preexisting untreated psychiatric disorder in the child, 3) family history of depression, and 4) high socioeconomic status.

CONCLUSIONS

A considerable number of the bereaved children developed the clinical symptoms of a major depressive episode immediately after the death of a parent. The relation of these symptoms to the subsequent course of grief and to major depressive disorder remains unknown and should be studied further.

Bipolar disorder in children: misdiagnosis, underdiagnosis, and future directions

Bipolar disorder has not been well studied in prepubertal children, despite its potentially debilitating effects on growth and development. However, there have been case reports of mania in this age group dating back to Esquirol in the mid-19th century. Despite anecdotal case reports, explicit criteria to diagnose mania in children were not used until 1960. Since 1980 the DSM-III/DSM-III-R criteria have indicated adult criteria can be used to diagnose childhood mania, with some modifications to adjust for age differences. Bipolar disorder has not been frequently considered in the psychiatric differential diagnosis of children. However, if a diagnosis of mania is made, clinical rating scales can be used to rate the severity of manic symptoms and to monitor treatment. A manic child should be treated using a biopsychosocial approach. To date, lithium carbonate has been the most commonly used psychopharmacological treatment, but results have been variable. Additional research is needed, including double-blind, placebo-controlled studies to document the beneficial effects of mood-stabilizing medications. Also, diagnostic instruments should be refined to improve their utility. Finally, children at high risk for developing mania should be studied to identify predictors of bipolar disorder in children.

Suicide-bereaved children and adolescents: a controlled longitudinal examination

OBJECTIVE

The current study examined emotional and behavioral sequelae in children who have experienced parental suicide by completing a secondary analysis of data from the Grief Research Study, a longitudinal study of childhood bereavement.

METHOD

Twenty-six suicide-bereaved (SB) children, aged 5 to 17 years, were compared with 332 children bereaved from parental death not caused by suicide (NSB) in interviews 1, 6, 13, and 25 months after the death. Children's emotional reactions to the death, psychiatric symptomatology, and psychosocial functioning after the parent's death were determined.

RESULTS

Grief emotions were common in both groups. SB children were more likely to experience anxiety, anger, and shame than NSB children. SB children were more likely to have preexisting behavioral problems and more behavioral and anxiety symptoms throughout the first 2 years compared with NSB children. Indices of depression, suicidality, and psychosocial functioning differed minimally between groups.

CONCLUSIONS

SB children experience some "common" elements of bereavement. In addition, they demonstrate some lifetime risk factors as well as subsequent pathology that suggests a negative behavioral trajectory. As these cohorts have not yet passed through the age of risk, long-term follow-up is critical.

The Mania Rating Scale (MRS): further reliability and validity studies with children

Empirical studies of prepubertal mania are scarce and are limited by a lack of assessment instruments. This study extended previous research on the Mania Rating Scale (MRS) in children. Psychometric properties of the MRS were examined in three new groups of prepubertal subjects: (1) 10 inpatients with bipolar disorder, (2) 10 inpatients with attention deficit hyperactivity disorder (ADHD), and (3) 10 outpatients with ADHD. Subjects were administered the MRS and other standard depression and hyperactivity measures. The MRS had adequate internal consistency (alpha = .80), convergent validity (r = .83, p < .0001), and divergent validity (no significant correlations with depression and hyperactivity ratings). Items assessing "classic" manic symptoms (e.g., elevated mood, increased sexual interest, pressured speech, racing thoughts) effectively discriminated the bipolar group from both comparison groups, while items assessing increased activity level and irritability did not. Results suggest that the MRS can be used with children.

Mania in prepubertal children: has it been underdiagnosed?

Prior to the introduction of lithium, mania was underdiagnosed in the U.S.A. Almost 50% of adults who met DSM-III criteria for mania had previously been diagnosed to have schizophrenia. To determine if mania had similarly been underdiagnosed in prepubertal children, 157 cases of 'severely disturbed' children described in the literature were reviewed. Approximately one-half (16/33) of the children diagnosed in this study as manic according to DSM-III had originally received another diagnosis. These results indicate that mania should be considered in the differential diagnosis of psychotic children, particularly those with affective symptoms.

Lithium treatment of manic episodes with psychotic features in prepubertal children

The authors describe the manic symptoms, family psychiatric histories, and psychotic symptoms of 10 prepubertal children 6-12 years old who had a DSM-III diagnosis of manic episode with psychotic features. All of the children improved when treated with lithium alone. Improvement in both manic and psychotic symptoms was noted an average of 11 days after lithium administration was started.

Study III: development and concurrent validity of the Children's Interview for Psychiatric Syndromes--parent version (P-ChIPS)

OBJECTIVE

To assess concurrent validity for the newly developed parent version of the Children's Interview for Psychiatric Syndromes (P-ChIPS).

METHOD

ChIPS and P-ChIPS were administered to 36 children 6 to 13 years of age and their parents. P-ChIPS results were compared with clinicians' diagnoses for 21 of those children. Either a standard or rare kappa coefficient and percentage agreement were used to assess concordance. Questions on P-ChIPS have a one-to-one correspondence with questions on the ChIPS, with the only change being from first to third person (e.g. "Have you ever . ." is replaced by "Has your child ever . . .").

RESULTS

There were moderate levels of agreement between the parent and child versions of the instrument, consistent with other reports of parent and child concordance on structured interviews in the literature. Likewise, there were moderate levels of agreement between the parent interview and clinician diagnoses, again consistent with other reports of parent and clinician concordance in the literature. Sensitivity averaged 87% across diagnostic categories, and average specificity was 76%.

CONCLUSION

P-ChIPS has adequate psychometric properties for use in clinical settings.

Suicide-bereaved children and adolescents: II. Parental and family functioning

OBJECTIVE

The current study extends the authors' earlier examination of suicide-bereaved (SB) children from the Grief Research Study, a longitudinal study of childhood bereavement after parental death, by examining the children's family history of psychopathology and family environment before and after death.

METHOD

Twenty-six SB children, aged 5 to 17 years, and their 15 surviving parents were compared with 332 children bereaved from parental death not caused by suicide (NSB) and their 201 surviving parents in interviews 1, 6, 13, and 25 months after the death.

RESULTS

Suicide completers evidenced more psychopathology than parents who died from reasons other than suicide. Contrary to expectations, surviving SB parents were not more impaired than NSB parents. Before the death, SB families were less stable than NSB families and relationships with the decreased SB parent were compromised. However, no differences were detected between groups in children's relationships with their surviving parents. Likewise, few differences were found in social support or changes in religious beliefs.

CONCLUSIONS

SB children generally come from families with a history of psychopathology and substantial family disruption. However, surviving SB parents do not exhibit higher rates of psychopathology than other bereaved parents and many have positive relationships with their children.

Plasma levels of imipramine and adverse effects in children

In 22 prepubertal depressed children, the total plasma concentration of imipramine and its major metabolite, desipramine, varied by more than sevenfold. The plasma drug concentrations correlated with slowing of intracardiac conduction, elevation of diastolic blood pressure, and increase in heart rate. These drug-induced changes were uniformly observed when the total tricyclic level exceeded 225 ng/ml. However, subjective reporting of nuisance side effects was not related to plasma drug concentration. These findings suggest that children can be safely treated when their plasma levels are below 225 ng/ml. If higher plasma levels are attained, closer monitoring is warranted.

Untoward effects of lithium treatment in children aged four through six years

OBJECTIVE

To explore the relationship between lithium dose and serum lithium level on the occurrence of untoward or toxic effects of lithium in the treatment of 20 hospitalized aggressive and/or mood-disordered children aged 4 through 6 years.

METHOD

Clinical and research records of 20 children treated with lithium according to an established inpatient protocol were reviewed. Side effects as reported by psychiatric staff were categorized by organ system affected and severity.

RESULTS

During the initial 2 weeks of lithium treatment, 60% of the children manifested one or more types of side effects, most commonly central nervous system effects. Side effects were seen at doses of 25.6 to 52.1 mg/kg per day and at serum levels from 0.65 to 1.37 mEq/L. In general, adverse effects were associated with higher lithium doses and lithium levels and were most common during the first week of treatment. A potential interaction between concurrent infection and more severe side effects was seen.

CONCLUSIONS

Side effects occur frequently in children aged 6 years and younger during the initiation phase of lithium treatment; are related to higher milligram per kilogram doses, higher serum lithium levels, and phase of treatment; and may be related to concurrent medical illness.

Psychosocial functioning in children after the death of a parent

Eight weeks after the death of a parent, children from stable families (N = 38) were compared to depressed inpatients (N = 38) and normal children (N = 19). School behavior, interest in school, peer involvement, peer enjoyment, and self-esteem were similar for bereaved and normal children. Bereaved children functioned significantly better than depressed inpatients. As a group, the bereaved children from stable families did not experience significant, acute psychosocial dysfunction.

Study IV: concurrent validity of the DSM-IV revised Children's Interview for Psychiatric Syndromes (ChIPS)

OBJECTIVE

To determine validity of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) revised Children's Interview for Psychiatric Syndromes (ChIPS) in inpatient children and adolescents.

METHOD

Participants were 47 psychiatric inpatients 6-12 (n = 23) and 12 to 18 years of age (n = 24). ChIPS was administered to all participants. The Diagnostic Interview for Children and Adolescents-Revised-Child Version (DICA-R-C) was administered to 40 participants. Discharge diagnoses were recorded for all participants. Kappas, low base rate kappas, and percentage agreement were used to assess diagnostic agreement between sources for 18 disorders.

RESULTS

ChIPS/DICA-R-C kappas could not be calculated for two disorders because of 100% agreement on their absence. Fourteen of 16 kappas were significant (p < 0.05). The remaining 2 of 16 disorders had 98% agreement (kappax = 0.494, p < 0.157). When ChIPS results were compared with discharge diagnoses, sensitivity for each disorder averaged 70%, whereas specificity averaged 84%. When disagreements occurred between all three sources, ChIPS was somewhat more likely than DICA-R-C to agree with discharge diagnoses (27% versus 22%). Analysis were repeated for children and adolescents, then for boys and girls. Boys and children had fewer significant ChIPS and DICA-R-C kappa coefficients compared with girls and adolescents; this appeared to be related to the fewer number of diagnoses they endorsed. ChIPS/clinician agreement was similar for boys and girls as well as for children and adolescents. Administration time was less for ChIPS than for DICA-R-C (p < 0.08).

CONCLUSION

Psychometric properties of the DSM-IV revised ChIPS compare favorably with that of other structured interviews. ChIPS appears to work well for adolescents as well as children.

Imipramine treatment of trichotillomania and coexisting depression in a seven-year-old

Trichotillomania is seen in normal children with a variety of psychiatric conditions (Krishnan, 1985). Although an association between depression and trichotillomania has been suggested in adults and adolescents (Krishnan, 1985), its association with DSM-III-R major depressive disorder in a prepubertal child has not been reported. Such a case of trichotillomania occurring with major depressive disorder is reported in this paper. In this prepubertal child, imipramine therapy led to remission of both disorders.

Study I: development and criterion validity of the Children's Interview for Psychiatric Syndromes (ChIPS)

OBJECTIVE

To test the psychometric properties of the Children's Interview for Psychiatric Syndromes (ChIPS), a second-generation structured diagnostic interview designed to improve on the methodology provided by first-generation structured interviews, which have increased diagnostic reliability over unstructured clinical interviews.

METHOD

Forty-two children hospitalized on a children's inpatient unit were administered the ChIPS and the Diagnostic Interview for Children and Adolescents (DICA). The level of agreement regarding syndrome presence or absence of 15 diagnoses according to the two instruments was assessed using a standard kappa coefficient or a rare kappa coefficient and percentage agreement.

RESULTS

Agreement between the two instruments was significant (p < 0.05) for 13 of 14 diagnoses for which either kappa coefficient could be calculated. Percentage agreement was 98% and 100% for the remaining two diagnoses. ChIPS and DICA results also were compared with a psychiatrist's diagnoses. Sensitivity was 80% for ChIPS and 61% for DICA. Specificity was 78% for ChIPS and 87% for DICA.

CONCLUSION

ChIPS is proposed as a valid measure of child psychopathology that offers advantages over existing interviews.

Study V: Children's Interview for Psychiatric Syndromes (ChIPS): psychometrics in two community samples

OBJECTIVE

To determine sensitivity and specificity of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) revised Children's Interview for Psychiatric Syndromes (ChIPS) in nonclinical samples.

METHOD

Participants were 40 children 6 to 18 years of age from a community sample (n = 22) or a bereaved sample 1 to 2 years following the death of a parent (n = 18). ChIPS and the Diagnostic Interview for Children and Adolescents (DICA-R-C) were administered in a Latin Square design. A consensus conference (CC) of child psychopathology experts determined presence or absence of syndromes or symptoms after reviewing assessment materials not including ChIPS.

RESULTS

Sensitivity is commensurate with epidemiologic base rates (17.5% of participants endorsed at least one syndrome). Low base rate kappas and percentage agreement were calculated to determine agreement on symptom or syndrome endorsement for 20 disorders. For syndrome analyses, over half the kappas could not be calculated due to 100% agreement on absence. For symptom analyses, 3 of 20 kappas could not be calculated (100% agreement on absence). Eleven of ChIPS/DICA-R-C symptom kappas were significant (p < 0.04), 2 of 17 had 95% agreement (kappas, p < 0.08), and 4 of 17 had 97.5% agreement (kappas, p < 0.16). Thirteen of 17 ChIPS/CC symptom kappas were significant (p < 0.04), and 4 of 17 had 97.5% agreement (kappas, p < 0.16).

CONCLUSION

ChIPS' psychometrics in nonclinical samples compares favorably with that of other structured interviews.

Plasma levels of imipramine and metabolites in 68 hospitalized children

Steady-state plasma imipramine levels were measured in 68 hospitalized children. Interindividual variability (imipramine 12-fold; desipramine 72-fold; 2 hydroxyimipramine 33-fold; 2 hydroxydesipramine 3-fold) was not correlated with clinical or demographic variables. However, intraindividual levels were reproducible and were linearly correlated with dose (r = 0.76; p less than 0.005). Clinicians, by using plasma level monitoring, can rationally adjust dosages so that all patients will be in the optimum range, ensuring an adequate trial while avoiding supratherapeutic levels associated with cognitive toxicity.

Treatment options in the management of adolescent depression

Treatment for depression in children and adolescents often requires pharmacotherapy with tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs), followed by psychotherapy. Most studies have not found the TCAs to be more effective than placebo in the treatment of depression in children and adolescents. Initial reports, however, have found the SSRIs to be more effective and better tolerated. In the small proportion of children who have treatment-resistant depression, TCAs plus lithium, monoamine oxidase inhibitors (MAOIs) or electroconvulsive therapy (ECT) may be useful. More studies on the treatment of depression in children and adolescents are needed, as adult data cannot simply be extrapolated.

Depression in adolescents growing pains or true morbidity?

This review discusses the prevalence and characteristics of depression in childhood and adolescence. Depression in this age group is a major public health concern, but is often under-recognised and dismissed as 'growing pains'. Interviewing the patient and their parents is essential for accurate diagnosis and structured interviews may be helpful. Prevalence increases with age. Risk of recurrence is high and is influenced by family conflict. Childhood onset depression has a 60-70% risk of continuing into adulthood and 20-40% develop bipolar disorder within 5 years. The nature of the disorder is affected by family history and symptoms vary with age. Comorbidity is common and influences treatment choice and long-term outcome. It is hoped that complications such as poor academic performance, impaired social functioning, and substance abuse may be prevented by early intervention.

The dexamethasone suppression test in hospitalized prepubertal depressed children

The dexamethasone suppression test was performed on 20 hospitalized prepubertal children who met DSM-III criteria for major depressive disorder. Fourteen children (70%) did not suppress cortisol secretion at either 8:00 a.m. or 4:00 p.m. The 4:00 p.m. value alone predicted 93% of the nonsuppressors.

Anxiety in acutely bereaved prepubertal children

Anxiety symptoms present immediately following parental death and approximately 8 weeks following the death were evaluated in 38 prepubertal children. Comparison groups included 38 hospitalized depressed children and 19 normal children. Bereaved children and parents were administered the Grief Interview and all were administered standard diagnostic interviews (DICA-C/P). While no bereaved children met DSM-III-R criteria for any anxiety disorder, anxiety regarding other family members dying was reported in 55% of bereaved children immediately after death and in 63% approximately 8 weeks later. When DSM-III-R anxiety symptoms were assessed, bereaved children did not report significantly more anxiety symptoms in the approximate 8-week interval post-parental death than normal comparison children, and had significantly fewer anxiety symptoms than depressed children (p < 0.0001). Bereaved children who had the most anxiety symptoms were also likely to have a depressive disorder (p < 0.002). Age and sex of child, sex of surviving parent, anticipation of death, and family history of anxiety or depressive disorders were not significantly associated with increased anxiety.