Pediatric emergency medicine trisk 1048

Symptoms of depression during adolescence are more similar to those
seen in adult-onset depression. The major symptom is a sad, unhappy or
irritable mood, and/or a pervasive loss of interest and pleasure. Other
symptoms may include a change in appetite, change in a sleep behavior, and
psychomotor retardation or agitation. Also present in many depressed
teenagers are loss of energy, feelings of worthlessness or excessive guilt,
decreased ability to concentrate, indecisiveness, and recurrent thoughts of
death or suicide. Depressed teenagers can also present with somatic
complaints, academic problems, promiscuity, drug or alcohol use, aggressive
behavior, and stealing. Many teenagers with behaviors such as these are
unaware of their depression, others simply deny it. In talking with these
patients about their lives at home, at school, and with peers, the underlying
depression usually becomes apparent.
A medical evaluation is needed to rule out potential medical causes,
concurrent medical illness, and to assess for self-injurious/suicidal behaviors
and side effects of prescribed medications. See Table 126.2 .
The AACAP Depression Resource Center can be accessed at
/>ression_Resource_Center/Depression_Resource_Center.aspx .
Management
The major goals in the management of depression in the ED involve (i)
determining suicidal risk (ii) uncovering acute precipitants, (iii) making an
appropriate disposition, and (iv) creating a safety plan.
ED physicians should screen for the presence of suicidal ideation as well
as any history of prior attempts. Direct questions about suicidal thoughts are
critical. They are unlikely to catalyze suicide attempts and may actually
provide a sense of relief for the depressed child.
The physician should attempt to determine possible acute precipitants to
guide subsequent recommendations. The duration of the depression should
be determined as well as the family’s response. Assessing overall adjustment
at home, in school, and with peers is important, as well as looking for the
strengths of child and family for use in the treatment plan.

Outpatient management may be considered when adequate social support
is present. Parental acknowledgment of the severity of and risk associated
with their child’s symptoms as well as a strong commitment to participating


in the child’s care are important first steps. Cognitive behavioral therapy is a
well-studied therapeutic intervention for pediatric depression. In moderate to
severe depression, therapy is most effective when combined with
antidepressant medications. Psychotropic medications should be prescribed
in the outpatient setting.
The emergency physician should be familiar with commonly used
antidepressants. Over the past several decades, the selective serotonin
reuptake inhibitors (SSRIs) have displaced TCAs as first-line medications.
Advantages of SSRIs over TCAs include a decreased likelihood of
cardiotoxicity, the absence of anticholinergic side effects, and the relative
safety of these medications when taken in overdose. Another commonly
prescribed antidepressant is bupropion, which is chemically distinct from
other agents and primarily acts on the dopaminergic system. Seizure is a
potential side effect. Newer mixed-mechanism agents such as duloxetine,
venlafaxine, and mirtazapine are also being used in children and adolescents.
Paroxetine, an SSRI, is generally avoided in pediatric patients due to its
short half-life and heightened concern for inducing suicidal ideation.
In December 2004, the FDA mandated a “Black Box” warning label on all
antidepressants. The labels warn about possible increased risk of suicidality
with these drugs and about the need to monitor patients for the worsening of
depression and the emergence of suicidal ideation. The agency advises that
children and adolescents on antidepressants should be closely monitored,
particularly after starting or increasing the dose of medication. Subsequent
research has supported the conclusion that, when prescribed appropriately
and with appropriate monitoring, SSRIs such as fluoxetine can be safe and

effective treatments for adolescent depression and their use correlates with
decreased suicide rates in the pediatric population.

MANIA/BIPOLAR DISORDER
Goals of Emergency Treatment
The goals of emergency treatment of mania include identifying and treating
any medical etiologies, providing acute pharmacologic interventions, and a
safe and appropriate disposition plan.
CLINICAL PEARLS AND PITFALLS


Unlike adults, mania in childhood may not always include euphoric
mood; irritable mood is much more common. Emotional lability is
common and can be disorienting to parents, who cannot understand
why the child changes so much and so dramatically. Unlike the older
adolescent, the child often does not have a clear recovery from
identified episodes but rather may exhibit continued irritability.
Explosive, disorganized behavior may also be seen. True psychotic
features are rare and the course of childhood bipolar disorder tends
to be chronic and continuous, rather than episodic.
Symptoms of bipolar disorder in adolescents are more similar to
the adult form. Psychotic symptoms, suicide attempts, inappropriate
sexual behavior, and a “stormy” first year of illness may be typical of
adolescent mania. However, when compared with adults,
adolescents may have a more prolonged early course and be less
responsive to treatment.
The adolescent with mania has a distinct period of predominantly
elevated, expansive, and/or irritable mood ( Table 126.22 ). The
patient has a significant decrease in need for sleep, high
distractibility, hyperactivity, pressured speech, and emotional lability.

Patients may also exhibit flight of ideas. The manic patient may have
inflated self-esteem, self-confidence, and grandiosity which may
also include delusional ideas. The person may be aggressive and
combative, go on buying sprees, pursue other reckless behaviors, or
be hypersexual. Manic patients usually have a history of previous
depressive episodes, but may present with an acute manic episode.
A family history of psychiatric disturbance usually exists in patients
with manic–depressive disorder. Typically, manic patients report
feeling extremely well, and they are often brought to the ED against
their will.
Sometimes, patients present with mixed episodes and have
symptoms of both mania and depression. Irritability is usually the
prominent manic symptom. Mixed episodes are particularly
dangerous with a significantly increased risk for suicidal behaviors.

Initial Assessment


Children presenting with symptoms suggestive of mania need a thorough
medical evaluation to rule out any potential medical causes of their
symptoms including possible toxin exposure ( Table 126.1 ). Assess for
potential medical sequelae of impaired judgment, such as sexually
transmitted infections, need for emergency contraception, or occult head
trauma. Laboratory and imaging workup should be based on history and
clinical findings.
TABLE 126.22
ACUTE MANIA IN ADOLESCENCE: MOST COMMON
FEATURES
Pressured speech
Grandiosity

Apparent “high” (euphoria)
Rapid shifts of emotion
Euphoria
Anxiety/irritability
Combativeness/panic
Hypersexuality
The AACAP Bipolar Resource Center can be accessed at
/>Disorder_Resource_Center/Home.aspx .

Management
Psychiatric consultation is indicated if a new diagnosis of bipolar disorder is
suspected, a manic/mixed episode is present, or if the patient is engaging in
any unsafe behaviors. In younger children, outpatient management—with
the combination of mood-stabilizing medications and intensive behavioral
treatment—may be sufficient. Inpatient hospitalization is often required to
maintain the patient’s safety while effective treatments are being initiated.
Patients who are manic can have severely impaired insight and judgment.
This can lead to dangerous behaviors that can have lifelong consequences