Other Types of Depression
Although rare in young children, bipolar disorder – also known as manic-depressive illness – can appear in both children and adolescents. Bipolar disorder, which involves unusual shifts in mood, energy, and functioning, may begin with either manic, depressive, or mixed manic and depressive symptoms. It is more likely to affect the children of parents who have the disorder. Twenty to 40 percent of adolescents with major depression develop bipolar disorder within 5 years after depression onset.
Existing evidence indicates that bipolar disorder beginning in childhood or early adolescence may be a different, possibly more severe form of the illness than older adolescent- and adult-onset bipolar disorder. When the illness begins before or soon after puberty, it is often characterized by a continuous, rapid-cycling, irritable, and mixed symptom state that may co-occur with disruptive behavior disorders, particularly attention deficit hyperactivity disorder (ADHD) or conduct disorder (CD), or may have features of these disorders as initial symptoms. In contrast, later adolescent- or adult-onset bipolar disorder tends to begin suddenly, often with a classic manic episode, and to have a more episodic pattern with relatively stable periods between episodes. There is also less co-occurring ADHD or CD among those with later onset illness.
Bipolar Disorder: Manic Symptoms
Severe changes in mood – either extremely irritable or overly silly and elated
Overly-inflated self-esteem; grandiosity
Decreased need for sleep – able to go with very little or no sleep for days without tiring
Increased talking – talks too much, too fast; changes topics too quickly; cannot be interrupted
Distractibility – attention moves constantly from one thing to the next
Hypersexuality – increased sexual thoughts, feelings, or behaviors; use of explicit sexual language
Increased goal-directed activity or physical agitation
Disregard of risk – excessive involvement in risky behaviors or activities
A child or adolescent who appears to be depressed and exhibits ADHD-like symptoms that are very severe, with excessive temper outbursts and mood changes, should be evaluated by a psychiatrist or psychologist with experience in bipolar disorder, particularly if there is a family history of the illness. This evaluation is especially important since psychostimulant medications, often prescribed for ADHD, may worsen manic symptoms. There is also limited evidence suggesting that some of the symptoms of ADHD may be a forerunner of full-blown mania.
The essential treatment of bipolar disorder in adults involves the use of appropriate doses of mood stabilizing medications, typically lithium and/or valproate, which are often very effective for controlling mania and preventing recurrences of manic and depressive episodes. Treatment of children and adolescents diagnosed with bipolar disorder is based mainly on experience with adults, since as yet there is very limited data on the safety and efficacy of mood stabilizing medications in youth. Researchers currently are evaluating both pharmacological and psychosocial interventions for bipolar disorder in young people.
Bipolar Disorder: A Warning About Antidepressants and Psychostimulants
Using antidepressant medication to treat depression in a person who has bipolar disorder may induce manic symptoms if it is taken without a mood stabilizer, such as lithium or valproate. In addition, using psychostimulant medications to treat ADHD or ADHD-like symptoms in a child or adolescent with bipolar disorder may worsen manic symptoms. While it can be hard to determine which young patients will become manic, there is a greater likelihood among children and adolescents who have a family history of bipolar disorder. If manic symptoms develop or markedly worsen during antidepressant or stimulant use, a child psychiatrist should be consulted, and treatment for bipolar disorder should be considered. Physicians should be aware of the signs and symptoms of mania so that they can educate families on how to recognize these and report them immediately.
According to studies conducted in Finland in patients with epilepsy, valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20. Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients prescribed valproate should be monitored carefully.
Dysthymic disorder (or dysthymia)
This less severe yet typically more chronic form of depression is diagnosed when depressed mood persists for at least one year in children or adolescents and is accompanied by at least two other symptoms of major depression. Dysthymia is associated with an increased risk for developing major depressive disorder, bipolar disorder, and substance abuse. Treatment of dysthmia may prevent the deterioration to more severe illness. If dysthymia is suspected in a young patient, referral to a mental health specialist is indicated for a comprehensive diagnostic evaluation and appropriate treatment.