Mood disorders

Pre-referral guidelines for primary care providers

Referrals
Prereferral guidelines A-Z index
Mood disorders

Referrals pathways for Regional Paediatric model

Index:

Diagnosis

Practice points

Management

Referral pathways

Mood disorders are common in children, particularly in adolescence and in those with co-morbid mental health and/or developmental/intellectual disorders.

This guideline will consider the following:

  • Depressive disorders
    • includes major depressive disorder and other subtypes
  • Anxiety disorders
    • includes generalised anxiety disorder, separation anxiety disorder, social phobia, specific phobia, agoraphobia, panic disorder & selective mutism
  • Obsessive compulsive disorder
    • includes body dysmorphic disorder, trichotillomania, hoarding disorder & excoriation disorder
  • Trauma- or stressor-related disorders
    • includes PTSD, reactive attachment disorder, adjustment disorder & acute stress disorder
  • Bipolar disorders
    • includes bipolar disorder I & II, bipolar disorder not-otherwise specified & cyclothymia

This guidelines does not cover schizophrenia and other psychotic disorders, dissociative disorders, somatic disorders or other psychiatric diagnoses that still need to be considered in children presenting with mood related symptoms.

Diagnosis

Mood disorders are a clinical diagnosis. We do not support the role for any routine blood tests or imaging modalities to assist with diagnosis, other than to exclude differential diagnoses.

Remember that a history taken with the patient alone and a HEADSS screen (see below) is very important when screening for mood disorders in adolescents. Considering the home and school environments for younger children remains paramount.

Always consider other differentials or co-morbidities when evaluating for mood disorders in children, such as ADHD, learning disorders, behavioural problems (incl. ODD, conduct disorder), intellectual disability, developmental delay,

The DSM-V is recommended in the diagnosis of mood disorders, with relevant points of some more common diagnoses listed below:

  • Major depressive disorder: lowered mood or anhedonia (lack of interest/enjoyment) for at least 2 weeks that is a change from baseline and is causing functional impairment, plus 5 of:
    • depressed or irritable mood, anhedonia, weight or appetite change, sleep disturbance, fatigue, agitation or psychomotor retardation, worthlessness/guilt, poor concentration, suicidality
    • in younger children: often we see agitation/irritability and poor concentration
  • Generalised anxiety disorder: excessive and difficult to control anxiety/worry more days than not for at least 6 months causing functional impairment, plus at least one of (in children):
    • restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance
  • Obsessive-compulsive disorder: presence of obsessions, compulsions or both, that are time consuming and cause functional impairment.
    • obsessions: recurrent and persistent unwanted thoughts or urges that cause anxiety/distress that the person attempts to suppress or ignore
    • compulsions: repetitive behaviours or mental acts aimed at reducing mental distress as a result of an obsession
  • Post-traumatic stress disorder: exposure to a specifically stipulated traumatic event that is persistently re-experienced with effortful avoidance or trauma-related stimuli over more than one month and causes functional impairment. There must also be onset of both of the following after the traumatic event:
    • persistent negative alteration in cognition or mood (at least two of): dissociative amnesia, negative self belief, distorted blame, negative trauma-related emotions, anhedonia, alienation, lowered affect
    • persistent alterations in arousal and reactivity (at least two of): irritability/aggression, self-destruction/recklessness, hyper-vigilance, exaggerated startle, poor concentration, sleep disturbance
  • Reactive attachment disorder: persistent emotionally withdrawn and inhibited behaviour towards adult care-givers due to pattern of extreme insufficiency of care (e.g. neglect, deprivation, repetitive change) starting prior to 5 years of age in a child over 9 months. This must be associated with:
    • persistent social & emotional disturbance (at least two of): minimal social/emotional responsiveness to others, limited positive affect, episodes of unexplained irritability/sadness/ fearfulness
  • Bipolar disorder: these disorders are highly controversial in the paediatric age group, with a move in the DSM-V to reduce the perceived over-diagnosis and over-treatment.
    • Categorisation:
      • bipolar I disorder (primarily mania with episodes of depression)
      • bipolar II disorder (recurrent depression with episodes of hypomania)
      • bipolar disorder not-otherwise specified (cycling depression/mania < 4 days but > 4 hours)
      • cyclothymic disorder (cycling depression/mania < 4 hours)
    • mania episode: at least 7 consecutive days of A & B symptoms
    • hypomania episode: at least 4 consecutive days of A & B symptoms
      • A symptoms (at least 1 of): mood elevation, irritability, modd instability
      • B symptoms (at least 3 of): grandiosity, decreased need for sleep, rapid speech, flight of ideas, high-risk behaviours, distractibility, increased goal-directed activities
    • depression episode: as major depression above

Various screening tools exist for mood disorders, such as the Child Behavioural Checklist (CBCL or Achenbach questionnaire), Spence questionnaires, etc.

HEADSS screen for adolescents:

  • Home
  • Education
  • Activities
  • Drugs & alcohol
  • Sexuality & suicidality

Practice points

  • Mood disorders are a clinical diagnosis. We do not support the role for any routine blood tests or imaging modalities to assist with diagnosis, other than to exclude differential diagnoses.
  • A history taken with the patient alone and a HEADSS screen is very important when screening for mood disorders in adolescents.
  • Considering the home and school environments for younger children remains paramount.
  • Self harm and suicidality must be screened for given it is a strong predictor of need to escalate therapy quickly.
  • Always consider other differentials or co-morbidities when evaluating for mood disorders in children.
  • Management centres around psychology services as the mainstay, with medication being considered when psychology therapies are not successful, or the presentation is severe.

Management

Investigations are seldom required in evaluating possible mood disorders, although can be considered to exclude organic differential diagnoses. Imaging is rarely warranted or helpful.

Management centres around psychology services as the mainstay, including adequate parental/ carer support and service provision. Medication is considered when psychology therapies are not successful, or the presentation is severe. Consider the following in management:

  • Self harm and suicidality must be screened for given it is a strong predictor of need to escalate therapy quickly.
  • If medication is required, first line medications generally involve:
    • SSRIs for depression, anxiety and/or OCD
    • specific symptom-related choices for trauma- or stressor-related disorders
    • sodium valproate and other mood stabilisers for bipolar disorders.

Referral pathways
  • Urgent assessments or suicidality
  • Psychologists, counsellors and social workers
    • Mental Health services are the mainstay of therapy for many mood disorders in children.
    • Refer families for psychology whilst awaiting paediatric review unless symptoms are severe.
  • Paediatrician
    • Many mood difficulties can be managed via mental health services and the general practitioner without paediatric involvement.
    • A non-urgent referral to paediatric outpatient services can be considered for more difficult to control mood disorders to i) confirm diagnosis, ii) discuss management strategies and iii) consider appropriateness of medication.
    • Information to bring to any appointments:
      • recent school reports and any written reports from teachers
      • any testing (cognitive, learning, etc)
      • behavioural questionnaires (if done)
  • School support services
    • For school who are having significant difficulties with a child's behaviour, there are various options for assistance, including both school support services and psychology services.
  • Other resources