Jeanne Rintelmann

Recurrence of Major Depressive Disorder in Hospitalized Children and Adolescents

OBJECTIVEnTo evaluate the outcome of a sample of children and adolescents hospitalized with major depressive disorder (MDD) and to assess different duration and severity criteria to define recovery and recurrence.nnnMETHODnFifty-nine of 70 children and adolescents were reevaluated 1 to 5 years later, and the intervening course of depression and other disorders was assessed using the Kiddie-Longitudinal interval Follow-up Evaluation (K-LIFE).nnnRESULTSnNinety-eight percent of subjects had recovered from their index MDD episode within 1 year of their initial evaluation, but 61% had at least one recurrence during the follow-up period. Of those with recurrences, 47.2% had a recurrence within 1 year and 69.4% by 2 years from the offset of the index episode. Changing the criteria for recovery by increasing the length of time required to define recovery resulted in decreases in the number of episodes of recurrence reported.nnnCONCLUSIONnMDD in children and adolescents is often an episodic disorder. Difference in definitions of recovery and recurrence affect the data reported. Consistent definitions of remission, recovery, relapse, and recurrence are needed. These data suggest that recovery may be defined after two consecutive months without symptoms and that episodes of MDD may be briefer, but more frequent, in children and adolescents than in adults.

Fluoxetine Versus Placebo in Preventing Relapse of Major Depression in Children and Adolescents

OBJECTIVEnThe authors compared fluoxetine and placebo in continuation treatment to prevent relapse of major depressive disorder in children and adolescents.nnnMETHODnAfter a detailed evaluation, children and adolescents 7-18 years of age with major depressive disorder were treated openly with fluoxetine. Those who had an adequate response after 12 weeks, as indicated by a Clinical Global Impression improvement score of 1 or 2 and a decrease of at least 50% in Childrens Depression Rating Scale-Revised score, were randomly assigned to receive fluoxetine or placebo for an additional 6 months. The primary outcome measures were relapse and time to relapse. Relapse was defined as either a score of 40 or higher on the Childrens Depression Rating Scale with a history of 2 weeks of clinical deterioration, or clinical deterioration as judged by the clinician. Additional analyses were conducted with relapse defined only as a score of 40 or higher on the Childrens Depression Rating Scale.nnnRESULTSnOf 168 participants enrolled in acute fluoxetine treatment, 102 were randomly assigned to continuation treatment with fluoxetine (N=50) or placebo (N=52). Of these, 21 participants (42.0%) in the fluoxetine group relapsed, compared with 36 (69.2%) in the placebo group, a significant difference. Similarly, under the stricter definition of relapse, fewer participants in the fluoxetine group relapsed (N=11; 22.0%) than in the placebo group (N=25; 48.1%). Time to relapse was significantly shorter in the placebo group.nnnCONCLUSIONSnContinuation treatment with fluoxetine was superior to placebo in preventing relapse and in increasing time to relapse in children and adolescents with major depression.

Depressive symptoms by self-report in adolescence: Phase I of the development of a questionnaire for depression by self-report

As the first step in validating a criteria-based, self-report depression questionnaire specifically for children and adolescents and to determine the prevalence of self-reported depressive symptoms, we studied 3,294 high school students of mixed ethnic background in a large urban school district. They completed the Weinberg Screening Affective Scale. The 21-item Beck Depression Inventory was also completed to allow comparison with a previous study. The prevalence of clinically significant depressive symptoms suggesting depression by self-report ranged from 18% on the Beck Depression Inventory to 13% on the Weinberg Screening Affective Scale. Hispanic females had the highest scores, while white males had the lowest. Being behind in school, female, and nonwhite predicted more self-reported depressive symptoms. (J Child Neurol 1989;3:114-121).

Delta sleep EEG in depressed adolescent females and healthy controls

BACKGROUNDnQuantitative EEG studies have identified a number of sleep abnormalities in adults with major depressive disorders (MDD), including a reduction in the amplitude of delta activity during NREM sleep. To date, these methodologies have not been used in early onset MDD.nnnMETHODSnDelta activity during NREM sleep was compared in eight symptomatic but unmedicated adolescent females with MDD and eight age- and gender-matched healthy controls.nnnRESULTSnThe depressed group showed significantly lower delta amplitude and power in the first NREM sleep period. By contrast, standard sleep architecture did not differentiate between groups.nnnLIMITATIONSnGiven the sample size, this study is best viewed as tentative. In addition, it has yet to be determined whether adolescent males with MDD also show delta sleep abnormalities. Further, failure to find between-group differences in REM latency or other macroarchitectural measures may be due to the small sample size.nnnCONCLUSIONSnThe findings of this study underscore the utility of quantitative sleep EEG techniques in early onset MDD. The results of the present study do, however, diverge from reports in adults with MDD, where delta abnormalities are more prevalent in men. Such findings suggest that the maturational time course of sleep EEG disturbances may differ for males and females with depression. Early emergence of delta abnormalities in depression may be of relevance to clinical course of illness.

A revised anchored version of the BPRS-C for childhood psychiatric disorders.

The Brief Psychiatric Rating Scale for Children (BPRS-C) is increasingly used as an outcome measure in research, managed care, and public sector child/adolescent clinical settings. The BPRS-C was developed to provide a descriptive profile of symptoms applicable to a broad range of child and adolescent psychiatric disorders. Its use frequently includes trained and untrained clinician raters with differing degrees of experience and training in child and adolescent disorders. Unfortunately, this latter approach leads to a large amount of variability in scores and consequently reduces its overall reliability. This study reports on a revised BPRS-C with the addition of clinical descriptive anchors designed to improve reliability and validity for both trained and untrained raters. A sample of 4,733 children and adolescents seen in 10 public sector facilities was administered the BPRS-C along with other standard clinical measures (Child Behavior Checklist and Global Assessment of Functioning). Additional reliability data were gathered in a University Medical Center child and adolescent research site with both trained and untrained raters. The data indicated improvement in overall reliability and validity scores, good internal consistency, and improved factor scores. The addition of an overall total severity score may prove to be a useful outcome measure for assessment of treatment response.

Ultradian rhythms and temporal coherence in sleep EEG in depressed children and adolescents

BACKGROUNDnIt has been suggested that a primary ultradian (80-120 minute) rhythm disturbance in EEG underlies sleep abnormalities in adults with depression. The present study evaluated ultradian rhythm disturbances in childhood and adolescent depression.nnnMETHODSnSleep macroarchitecture and temporal coherence in quantitative EEG rhythms were investigated in 50 medication-free outpatients with major depression (25 children and 25 adolescents) and 15 healthy normal controls (5 children and 10 adolescents).nnnRESULTSnFew of the macroarchitectural measures showed significant group effects. In fact, age and sex effects were stronger than disease-dependent components. Temporal coherence of EEG rhythms during sleep did differentiate those with MDD from controls. Both depressed children and adolescents had lower intrahemispheric coherence, whereas interhemispheric was only lower in depressed adolescents in comparison with controls. Gender differences were evident in adolescents, but not children, with MDD with lowest interhemispheric coherence in adolescent girls.nnnCONCLUSIONSnThese findings are in keeping with increased risk for depression in females beginning at adolescence and extending throughout adulthood. It was suggested that low temporal coherence in depression reflects a disruption in the fundamental basic rest-activity cycle of arousal and organization in the brain that is strongly influenced by gender.

The effect of fluoxetine on sleep EEG in childhood depression : A preliminary report

Fluoxetine is associated with substantial objective and subjective sleep disturbance in adults with major depressive disorders. In this preliminary report, the effects of fluoxetine on sleep electroencephologram (EEG) are described in 6 children and adolescents with nonpsychotic major depression. Fluoxetine increased light Stage 1 sleep, the number of arousals and rapid eye movement (REM) density. REM latency was largely unaffected. Oculomotor abnormalities were also evident on treatment, accompanied by an increase in myoclonic activity. Subjective sleep was also disturbed on treatment. These results are in keeping with those observed in depressed adults treated with fluoxetine.

Attention Training for School-Aged Children with ADHD: Results of an Open Trial.

Objective: The article discusses a feasibility study conducted to examine whether Pay Attention!, an intervention training sustained, selective, alternating, and divided attention, could be utilized in a clinical setting with children diagnosed with ADHD, and whether children who received the intervention made attention and executive functioning gains. Method: After a diagnostic and baseline evaluation, 23 school-aged children with ADHD participate in up to 16 sessions of Pay Attention! and the outcomes are evaluated. Results: Results show the intervention is feasible to administer and acceptable to participants. Parents and clinicians rate fewer ADHD symptoms following the intervention and report improvements in executive function. Child performance on neuropsychological tests showed improvements in fluid reasoning and cognitive flexibility and working memory. Conclusion: The findings suggest that a randomized clinical trial of Pay Attention! is warranted to investigate its viability as a treatment for attention and executive functioning deficits in ADHD. (J. of Att. Dis. 2010; 14(1) 86-94)

Sleep microarchitecture in childhood and adolescent depression : Temporal coherence

Previous work has indicated that low temporal coherence of ultradian sleep EEG rhythms is characteristic of depressed patients and women in particular. It may also be evident in depressed children and adolescents, although most published studies are limited in sample size. The present study evaluated temporal coherence of sleep EEG rhythms in 173 children and adolescents 8–17 years of age, including 97 who met criteria for major depressive disorder (MDD) and were symptomatic but unmedicated at the time of study and 76 healthy controls. Temporal coherence of all-night sleep EEG rhythms was evaluated on the second of two nights in the laboratory. Data were coded for diagnostic group, gender and age and subjected to MANOVAs. Temporal coherence was significantly lower in adolescents with MDD, compared to healthy controls. Findings were most robust for coherence between left and right beta and between delta and beta in both hemispheres. Both gender and age strongly influenced between-group differences, with the lowest temporal coherence among MDD girls, even in those under 13 years of age. In conclusion, early onset depression is associated with a reduction in synchronization of sleep EEG rhythms that shows a differential maturational course in boys and girls.

Do children and adolescents have differential response rates in placebo-controlled trials of fluoxetine?

OBJECTIVEnRecent acute efficacy trials of antidepressants in youth have suggested that high placebo-response rates in children (< 12 years of age) indicate that children may be more responsive to non-specific treatment interventions. Yet, these studies generally have not presented age-specific outcome data. The objective of this study was to compare the efficacy outcomes for children (< 12 years of age) and adolescents (> or = 12 years of age) using the combined data from two previously published double-blind, placebo-controlled trials of fluoxetine.nnnMETHODSnChildren (< 12 years of age) and adolescents (> or = 12 years of age) with major depressive disorder were randomized to fluoxetine or placebo for 8-9 weeks of treatment. Outcome was assessed using the Childrens Depression Rating Scale-Revised (CDRS-R) and Clinical Global Impressions scale.nnnRESULTSnRandom regression of the CDRS-R showed a treatment group by age group interaction (F(1,338)=4.10, P=.044), indicating that the treatment effect was significantly more pronounced in children than adolescents. Within children, response at exit to fluoxetine was significantly better than placebo (56.9% vs 33.3%; P=.009). Adolescent response rates at exit were not significantly different between the groups (51.1% vs 38.6%; P=.128). Remission rates were low for both groups.nnnCONCLUSIONnIn the combined fluoxetine trials, drug-placebo difference was greater in children compared with adolescents. Contrary to expectations, the placebo-response rate was lower in the children than the adolescents.