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For Parents

Getting Started

Parents with newly diagnosed children or those who suspect that their child may have a mood disorder may also find value from this brochure, Getting Started.

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A special thank you to Karen Cruise, Nanci Schiman, and Jean Meister for their help in developing this document.

Learning that your child has a mood disorder can be frightening and disorienting. You are suddenly plunged into a new world of confusing medical terms, treatment options, and clinician choices while facing decisions about appropriate education for your child and how to best manage the needs of your family. You may feel very alone and unsure of what to do.

The Balanced Mind Parent Network (BMPN) was created for people just like you. It’s an online, family-focused community for parents of children with mood disorders. You can turn to BMPN for information about your child’s behavior and needs, as well as reliable information about mood disorders, treatment, school accommodations, scientific research, and more. This document walks you through some steps to take when getting started. First, items to consider include

  • getting support for yourself; 
  • building the proper treatment team for your child; 
  • expanding your knowledge of depression or bipolar disorder; 
  • looking at how your child’s illness affects his or her education.

This guide is filled with advice from the BMPN parents—people who collectively have dealt with all of these issues and more. You will also find plenty of information, references to websites, books and other resources that will help you help your child.

Getting Support for Yourself

Mental health conditions can be isolating. Having a support system in place is an important step in ensuring you can go the distance in supporting and advocating for your child. Connecting with other parents who have had similar experiences and who can offer comfort and encouragement will give you strength, hope, and encouragement. Peer support is an incredible resource when no one else seems to understand, when blame seems to be coming from all sides, or when you need information and ideas.

Support comes in several forms.

DBSA’s online support community, the Balanced Mind Parent Network (BMPN), provides 24/7 access to information and support which can be ideal for those who want more frequent interaction or are unable to attend in-person meetings. BMPN is a great way to connect with other families and develop mutually beneficial friendships.

The communities are private, which means that only other community members can interact within the group. They combine the support of other parents who have had similar experiences and their collective knowledge, as well as conversational, sometimes off-topic discussions. Most people send and receive messages via email. However, you can read and post at the website, or receive a daily digest of all posts bundled into one email. Join an online support community today!

When The Balanced Mind Parent Network participants were asked to name one of the things they found most helpful when they first joined, many said it was connecting with others through the online support programming. Here are some of their comments.

  • I like knowing support is a click away . . . a refuge for the most challenging days in my home.
  • I enjoy the sense of community and easy access to parents who understand my situation.
  • I feel a part of a group of others with similar struggles.
  • I receive totally non-judgmental support from people in the trenches.
  • I can log on when needed to get the support I need. If something has not gone well that day, I can vent, get support.
  • It's important for parents to have other people to connect with who are living with the same experiences. Parents of older children can share their wisdom with "newbies" to the diagnosis.
  • I don't think I could have survived the past few years without the moral and emotional support of my on-line friends. I have met people who have experienced what I am experiencing, and not only do they support me, but I can step outside of my own problems by trying to help them.

If you prefer face-to-face support, many of DBSA’s chapters offer in-person support groups for families and friends. You can search for a DBSA support group in your area through DBSAlliance.org/FindSupport. Groups meet anywhere from once a week to once a month at a scheduled time and location. Your local psychiatric hospital and your child’s doctor or therapist may have additional suggestions. 

Two other organizations that might be helpful to you in finding local support are The National Alliance on Mental Illness (NAMI) and The Federation of Families for Children’s Mental Health. Both of these organizations have chapters throughout the country.

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Understanding Pediatric Depression

Children and teens can develop depression, just like adults. Childhood depression is a sad or irritable mood that lasts at least several days and causes problems in a child or teen’s normal activities, such as school, social life, and relationships with family and peers. About five percent of children and adolescents experience depression at any point in time, according to the American Academy of Child and Adolescent Psychiatry (AACAP).

It’s important to treat depression early rather that assume it will go away on its own. A child or teen can’t “just snap out of” it. Without treatment, childhood depression may last longer and can worsen. Children and teens who are untreated are at increased risk for problems in school, substance abuse, and suicide.

According to a study by Wisdom, Clarke, and Green, only half of adolescents with depression contact any healthcare professional, and just 20 to 30 percent of teens with major depression—the most severe form of the disorder—receive treatment (“What Teens Want: Barriers to Seeking Care for Depression,” Administration and Policy in Mental Health, March 2006). Often, adolescents with depression underestimate the severity of their symptoms and their risk for harm. A study by Culp and Clyman showed that many teens who do not receive treatment believe they must manage their problems themselves (“Adolescent Depressed Mood, Reports of Suicide Attempts, and Asking for Help,” Adolescence, winter 1995).

Any episode of depression calls for future vigilance. If your child has experienced depression in the past, he or she is at a higher risk in the future. Sometimes it can be difficult to tell the difference between childhood or teenage depression and a depressive episode in bipolar disorder. Depression also is often accompanied by anxiety.

Signs of depression

 If you are concerned that your child is unusually sad, talk with your child about feelings and things that may be bothering him or her at school, at home, or with peers. Ask about bullying. Take steps to reduce stress that your child may be shouldering. Ask your child if he or she is thinking of self-harm or suicide. Contact your child’s teacher to ask if your child has shown unusual or worrisome behaviors at school.

Here is how one Balanced Mind Parent Network mother knew it was time to seek help: 

“My daughter was a pretty typical child until her depression hit at age 11. She woke up one day and was low. She didn’t want to go to her friend’s house anymore . . . Our family took a trip to the beach for a weekend and she barely smiled, she showed no joy. There was nothing to be sad about, no changes in her life, and no physical illness. That’s how I knew it wasn’t just sadness. My advice to other parents would be don’t wait for it to go away.

Trust your instincts. If you think your child is depressed, schedule an appointment with your child’s physician as soon as possible. The physician may do a physical exam, including lab tests to determine blood count and thyroid function which can affect mood and energy. A physician will also ask your child or teen about his or her thoughts, feelings, and behavior. Your child’s doctor may recommend evaluation or treatment by a child and adolescent psychiatrist or other mental health professional with expertise in treating children and teens.

Symptoms of depression in children and teens include:

  • frequent sadness, or crying, or constant irritability;
  • loss of interest in activities that used to be enjoyable;
  • lack of energy, difficulty concentrating, or making choices;
  • feelings of hopelessness, worthlessness, or guilt;
  • withdrawing from friends and family;
  • a marked change in weight or eating, up or down;
  • complaints of stomachaches and/or headaches when no physical cause can be found;
  • frequent absences from school or a drop in school performance;
  • sleeping too little at night or too much during the day;
  • thoughts of death or suicide and/or self-destructive behavior.

There are also online resources that you might find helpful, including  Getting an Accurate Diagnosis for your Child: 10 Steps for Families (National Alliance on Mental Illness). Families can use this to help their mental health service provider make an accurate diagnosis.

If you think your child is in immediate danger of self-harm or suicide, do not leave your child alone. Ensure that someone stays with your child. Call 911 or your local crisis line immediately. If you think it is safe to transport your child, take him or her to the nearest hospital emergency department. Consider activating the child-lock in your car and having another adult ride in the back seat with your child.

Diagnosing Pediatric Depression

Depression is diagnosed based on symptoms including behavior and impaired functioning, feelings that your child may express, observations of parents and others, and the absence of physical causes. In addition, a clinician will ask about family history of depression or other psychiatric disorders.

Screening for depression includes an assessment of suicidal ideas or plans. If a child or teen has a plan for suicide or has attempted suicide, he or she is likely to be hospitalized for treatment. In some cases, psychosis may occur with depression. Assessment tools such as the Beck Depression Inventory, the Children’s Depression Inventory, the Reynolds Adolescent Inventory, or the Columbia Depression Scale (Teen) may be used to measure severity, baseline functioning, and to monitor the progress of treatment.

The Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5) guides psychiatrists and other physicians in diagnosing disorders including depression. The DSM-5 includes seven depressive disorders that can affect children and adolescents.

Major Depressive Disorder (MDD) The DSM-5 criteria includes a depressed or irritable mood that lasts at least 2 weeks and the loss of interest or pleasure in activities once enjoyed. Symptoms must cause significant distress or impairment in functioning, often across multiple settings such as school, home, and peer relationships.

A diagnosis of MDD also requires the presence of five or more of the following symptoms:

  • Significant weight loss or decrease in appetite
  • Sleeping too much or too little
  • Restlessness or slowed behavior
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Difficulty making decisions or concentrating
  • Reoccurring thoughts of death or suicide 

The onset of depression is most common during or after puberty. Other depressive symptoms can include a persistent sad or irritable mood; anger or hostility; complaining of physical illness or pain when no physical cause can be found; frequent absences from school or a drop in school performance; and reckless behavior or substance abuse.

Disruptive Mood Dysregulation Disorder (DMDD) The primary feature of DMDD is chronic, severe persistent irritability with frequent temper outbursts, beginning before age 10 and after the developmental age of six. This disorder was added to the DSM-5 to address concerns about over diagnosis of bipolar disorder in children and to provide classification and treatment for children with extreme irritability but without mania or other symptoms of pediatric bipolar disorder. Children with DMDD are believed to be at increased risk for unipolar depression and anxiety disorders in adulthood.

Persistent Depressive Disorder This condition is diagnosed when a child has a depressed mood or irritability for most of the day or for more days than not over a year. The child also must have two other symptoms, such as significant changes in appetite, sleeping too much or too little, low self-esteem, problems with decision-making or concentration, and/or feelings of hopelessness.

Substance/Medication Induced Depressive Disorder This condition is diagnosed when depressive symptoms are severe and develop during or soon after treatment with or use of a substance like alcohol, marijuana, hallucinogens, inhalants or stimulants including cocaine, and other opioids. Symptoms persist after use but usually lessen over time. Medications that can cause depressive symptoms include steroids, stimulants, antibiotics, central nervous system drugs, dermatological drugs, antiviral medications, oral contraceptives, and smoking cessation treatments.

Depressive Disorder Due to another Medical Condition Depressed mood is a predominant symptom of this disorder which occurs because of another medical condition such as endocrine disease, cardiovascular disorders, metabolic disturbances, and neurological illness.

Premenstrual Dysphoric Disorder This condition is the repeated occurrence of mood shifts, irritability, and anxiety symptoms during the premenstrual phase of the menstrual cycle.

Other or Unspecified Depressive Disorder This form of depression that includes irritability or the inability to experience pleasure, and up to three symptoms of major depressive disorder.

A Diagnosis of depression can be tricky because other conditions sometimes resemble it or may occur along with depression. These include

  • adjustment disorder with depressed mood;
  • adjustment disorder with depressed mood and anxiety;
  • anxiety disorders;
  • post-traumatic stress disorder;
  • depressive episode of bipolar disorder;
  • manic episodes with irritable mood or mixed episodes of bipolar disorder;
  • eating disorders;
  • attention deficit hyperactivity disorder;
  • normal teen moodiness.

The co-occurrence of other disorders along with depression is significant. Studies have found that 30 to 70 percent of children and adolescents with depressive disorders also have an anxiety disorder. Substance abuse disorders occur in an estimated 20 to 30 percent of adolescents with depression. Disruptive behavior disorders, including oppositional defiant disorder and conduct disorder, also commonly co-occur with depression.  (Castro and Gathright, Depression in Children and Adolescents, 2013)

Depression in children can predict chronic or episodic depression throughout an individual’s lifespan. It is estimated that 40 percent of children and teens with a single depressive episode will develop depression again within two years, and that 70 percent will have a second episode within five years (Frosted and Goldberg, Raising a Moody Child, 2003).

Early treatment will often reduce the severity of episodes and help the child better handle any future episodes. 

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Understanding Pediatric Bipolar Disorder

Bipolar disorder is a chronic brain disorder marked by bouts of extreme and impairing changes in mood, energy, thinking, and behavior. Symptoms may emerge gradually or suddenly during childhood, adolescence, or adulthood.

Bipolar disorder does not affect every child in the same way. The frequency, intensity, and duration of a child’s symptoms and the child’s response to treatment vary dramatically.    

There is presently no cure for bipolar disorder, however many people with this condition go on to live happy, successful lives. Research to help children and adults with this condition is ongoing. Genetic discoveries and medical advancements are expected to lead to more accurate diagnosing, better treatments, and perhaps, a cure.

Diagnosing Pediatric Bipolar Disorder

As with depression, the Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5) guides psychiatrists and other physicians in diagnosing disorders including bipolar disorder.

Bipolar disorder is defined by periods of mania or hypomania.  That means a distinct period of abnormally elevated, expansive or irritable mood – accompanied by other symptoms such as:

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • Being more talkative than usual or feeling pressure to keep talking
  • Racing thoughts
  • Being easily distracted
  • Feeling or acting driven to do things
  • Doing risky or impulsive things regardless of the consequences

A manic episode is identified as a distinct period of elevated, expansive, or irritable mood that lasts at least a week or is severe enough to lead to hospitalization – and is accompanied by at least 3 of the symptoms above.

The difference between a manic episode and a hypomanic episode is the duration of the episode. Hypomania lasts a shorter period of time, but must last at least 4 days. 

Even one manic episode makes an official diagnosis of bipolar disorder.  But most children and adolescents with bipolar disorder also experience periods of depression.  Depressed periods are usually more common and last longer than manic or hypomanic periods.  And “mixed” periods (with symptoms of both depression and mania) are likely more common than pure manic or hypomanic periods.  The depression part of bipolar disorder is often apparent earlier or is easier to recognize.

In children and adolescents with depression, it is sometimes hard to distinguish symptoms of mania or hypomania from other conditions that often go along with depression, including:

  • Attention deficit disorders
  • Anxiety disorders (generalized anxiety, panic disorder, obsessive-compulsive disorder)
  • Disruptive behavior disorders (conduct disorder, oppositional defiant disorder)

This is not an “either-or” question.  Children and adolescents can have a bipolar disorder along with an anxiety disorder, attention deficit disorder, or a disruptive behavior disorder.

Diagnostic rules describe two categories of “full” bipolar disorder:

  • Bipolar I (or Type I bipolar disorder) is defined by at least one full manic episode (lasting at least 7 days or resulting in hospitalization).  Officially, a manic episode with no history of depression makes a diagnosis of Bipolar I, but most people with Bipolar 1 have had episodes of significant depression.
  • Bipolar II (or Type II bipolar disorder) is defined by episodes of both depression and hypomania (lasting at least 4 days).  Most people with Bipolar II have repeated episodes of depression.

Diagnostic rules for bipolar disorder also describe two related conditions

  • Bipolar NOS (or Bipolar Disorder Not Otherwise Specified) is defined by a pattern of “bipolar features” – periods with symptoms of depression and mania that are not severe enough or long enough to make a diagnosis of full bipolar disorder.
  • Cyclothymic Disorder (or Cyclothymia) is defined by repeated periods of depression and elevated mood – when those period are not severe enough to make an official diagnosis of mania/hypomania or a major depressive episode.  This is a long-term condition, so the diagnosis would not be applied to problems present for less than a year.

One of the longest studies on pediatric bipolar disorder was led under the direction of Barbara Geller, M.D., a child psychiatrist at Washington University in St. Louis. In the mid-1990s, Dr. Geller began observing 93 children whose average age was 10.8 years. All of the children had mania (Bipolar I) which had begun to onset at an average age of 6.8 years. Assessing the children after four years, Geller and colleagues found that children with mania were more severely impacted than adults. (Geller, Tillman, Craney and Bolhofner, Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype, 2004.)

Another study of three major subtypes of bipolar disorder that affect children and adolescents is ongoing under the direction of David Axelson, M.D., a child psychiatrist at Western Psychiatric Institutes and Clinics in Pittsburgh. A report on the 263 children and adolescents, ages 7-17 years, confirmed that bipolar disorder affects children and adolescents more severely than adults. “Study participants had comparatively longer symptomatic stages and more frequent cycling (changing from one mood to another) or mixed episodes. Children and adolescents also converted from a less severe form of bipolar disorder to a more severe form at a much higher rate than seen in adults.”

Genetics

Bipolar disorder is a complex condition that may have genetic links. The following statistics support the search for the genetic origins of bipolar disorder:

  • For the general population, a conservative estimate of an individual's risk of having Bipolar I disorder is 1% to 3%. Disorders in the bipolar spectrum are thought to affect at least 4% to 6 % of the general population.
  • When one parent has bipolar disorder, the risk that his or her child will have bipolar disorder is 15% to 30%.
  • When both parents have bipolar disorder, the risk increases to 50% to 75%.
  • If a sibling (including a fraternal twin) has bipolar disorder, the child's risk is 15% to 25%.
  • The risk in identical twins is approximately 85%.

The family trees of many children who develop pediatric bipolar disorder include individuals who lived with mood, substance abuse, or other psychiatric disorders. Previous generations were less likely to diagnose bipolar disorder and it is helpful when gathering family history to identify individuals who may have exhibited symptoms of mania or depression.

Prevalence

There are very few studies that establish the prevalence of bipolar disorder in children. In a review of data in the Netherlands Twin Registry, 4% to 5% of more than 6,000 ten-year-olds were deemed likely to meet criteria for pediatric bipolar disorder.

Another study showed a 40-fold increase in the diagnosis of bipolar disorder in the US in the past ten years. The study reveals that in 1994, very few doctors wished to label children as bipolar (25 bipolar diagnoses per 100,000 people). Yet even the 40-fold increase rate in 2003 (1,003 bipolar diagnoses per 100,000 people) is still well below the rate of bipolar disorder for adults (1,679 bipolar diagnoses per 100,000 people.)  Further, a long-term NIMH study of adults shows at least 65% felt their illness onset in childhood or adolescence and acknowledges a lag between onset and diagnosis in adults.

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Finding a Treatment Team

DBSA encourages you to have your child evaluated and treated by a psychiatrist who works with children with mood disorders. You can find a list of professionals on our website under Find a Professional Resource. You can also search the American Academy of Child & Adolescent Psychiatry (AACAP) Doctor Directory. You might also want to take a look at The Doctor's Visit: A Parent Checklist of Questions. This tool will provide information on how to choose a clinician, prepare for a doctor’s visit, and how to maximize your time with the doctor.  

Here are some words of advice from The Balanced Mind Parent Network participants on working with the treatment team.

In our rural community psychiatrists are limited and not up to date. We ended up making a six-hour drive to a specialist after many other doctors and programs failed to help adequately. Many were adolescent specialists. Some said they had considerable experience with bipolar disorder. However, it was the adolescent bipolar specialist we needed, and wished we had gone to in the beginning. It would have saved years of suffering, danger, and money to have gone to him in the start!!!

It's ok to ask lots and lots of questions.

Look for pdocs (psychiatrists) and tdocs (therapists) who see you all as part of a treatment team.

Finding a good psychiatrist or psychiatrist/therapist team is an important step in the treatment of childhood depression or bipolar disorder. Talk to your child’s pediatrician or family practice physician, local therapists, clergy, and other parents to learn which psychiatrists in your community best fit your needs.

When you meet with a psychiatrist or other physician, ask about diagnosis and treatment options. Mental health treatments must be tailored to the individual. Mood disorders can be tricky to diagnose, especially for children and teens. Don’t hesitate to seek a second opinion. Some parents interview clinical team members over the phone to see if their philosophies align.

First Steps

Parents with concerns about their child’s extreme behaviors should consider the following steps:

  • If your child is at risk of harming themselves or others: take him or her to the emergency room or call 911 for an ambulance. If you are alone, also call a friend or relative to help you immediately. Immediate assistance may also be necessary if your child is experiencing psychosis.   Psychosis is when an individual experiences hallucinations (seeing, hearing, or feeling things that are not there) or delusions (strong beliefs that are unlikely to be true and may seem irrational to other).
  • Ensure the safety of your family. Consider finding care or support for siblings.
  • Childproof your home, no matter the age of your child. Remove all firearms from the home. Lock up sharp objects such as knives or razors and all prescription and over-the-counter medications.
  • Request an urgent appointment to have your child evaluated by a medical professional familiar with pediatric bipolar disorder. There are many items to consider including insurance requirements and any needed referral steps.
  • Prepare for the initial meeting with a medical professional: 
    • Start a mood chart for your child. Make daily notes of your child's mood, behavior, sleep patterns, events, and medications. Include statements by the child that seem odd or concern you. See below for more information on mood charting.
    •  Compile a brief family history on both sides, including family members living with a substance abuse, mood, or other psychiatric disorders. It may also be helpful to list any family members who may have exhibited symptoms of a mental health condition, but does not have a formal diagnosis.  
  •  Keep a notebook or file in which you keep mood charts, family history, doctor visit summaries, lab test results, as well as a list of all medications your child has taken, the dates, the doses, and the effects.
  • Educate yourself about bipolar disorder. DBSA offers several online resources, including access to parental peer support through its program, the Balanced Mind Parent Network.
  • Take care of yourself! Your health and well-being matters, and it can be difficult to focus on yourself when a child is struggling. Consider ways to gain support and practice self-care routines.

Mood Charts and Other Helpful Tools

Keeping a daily chart of your child's mood, sleep, energy, medications, psychotherapy sessions, and statements or events of concern can be extremely helpful not only to you, but also to professionals, parents, and (as the child matures) the child themselves.  Treatment of early onset bipolar disorder or depression can involve numerous trials of different treatments, alone or in combination. Keeping a daily chart will help you remember the effects of different medications. The main thing is to keep with it on a regular basis, until your child reaches stability. You may even wish to continue after stability has been reached in order to stay tuned in to any possible changes.

You can chart with a calendar, a notebook, or on a computer. Charts can consist of colors or a few words that describe your child’s behavior and mood at regular intervals. Time of day can be key. Many children or teens struggle to sleep at night and wake in the morning, or they melt down at home after school. Note anything that may have affected your child’s mood. Keep track if your child has a cold or did not sleep well. Record any medicine changes as well as skills that your child used to cope, such as seeking a quiet space, journaling, or listening to music. DBSA offers a printable personal calendar as well as a mood tracking app for smartphones or to be used on the web. There are numerous different types of charts; find one that works for you.

The Columbia Impairment Scale (Parent Version) is another valuable tool. This assessment is a single page questionnaire that can help parents rate how well a child or teen functions in relationships with family and friends, at school, in sports or activities, as well as the child’s behavior and feelings. This record can help your child’s clinician to identify areas in which the child needs help, as well as his or her progress over time.

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Treatment Options

It is important that you and your child work with your child’s care team to establish treatment goals. You may start by addressing your child’s severest symptoms, such as suicidal thoughts and actions, aggression, destructive behavior, psychosis, and sleep disturbances.  The long-range goals of treatment are to stabilize mood and extend the period of wellness.  

There are many components that you may include in your child’s treatment plan, which may include:

  • Medication and monitoring of side effects
  • Close monitoring of symptoms 
  • Education about the condition for your child and you 
  • Psychotherapy for your child and family 
  • Treatment of coexisting disorders 
  • Accommodations at school 
  • Stress reduction 
  • Good nutrition and steady exercise 
  • Adherence to a regular sleeping schedule and a consistent routine

Responses to treatment vary greatly. With appropriate treatment and support at home and at school, many children with a mood disorder achieve a marked reduction in the severity, frequency, and duration of mood episodes. Just as with other chronic illnesses such as diabetes and epilepsy, children who are educated about mood disorders can learn how to manage and monitor their symptoms as they grow older, and some experience long periods of wellness. 

Factors that often contribute to a better outcome are:

  • Early diagnosis and treatment. 
  • Access to competent medical care.   
  • Adherence to medication and treatment plan. 
  • A flexible but consistent low-stress home and school environment 
  • A supportive network of family and friends 
  • Family members who are effective advocates for the child’s medical, educational, and therapeutic needs

In most cases, symptoms can be managed at home with outpatient treatment. Children who are a danger to themselves or others or those who do not respond to outpatient treatments may require support in an inpatient setting. Some families also benefit from the services provided in a longer, residential setting such as a residential treatment center or a therapeutic boarding school.

It is important that you speak with your child’s care team to not only choose the best treatment options, but understand how and when they will be implemented.

Medications Overview

Each individual is different and finding the right medication usually involves a period of trial and error. Some medications take four to six weeks or longer to take effect. If your child’s symptoms are not getting better, ask the psychiatrist or physician to explain his or her treatment plan, including how long it may take to notice results and how you will decide when it is time to adjust or change medications. Encourage your child or teen to ask questions too.

Questions that you may wish to ask about medications are:

  • Why is medication recommended?
  • What are the expected benefits?
  • What are the potential side effects?
  • When should symptoms start to improve?
  • How will the prescriber determine if a change in medication or dosage is needed?

Carefully supervise your child’s use of medications. In order to work properly, medications must be taken consistently and at the prescribed dosage. Parental monitoring also is important because overdose can be a risk for teens with depression. Some medications also can cause withdrawal symptoms so the dosage must be tapered off when switching to a different medication.

Because of the lack of controlled studies, the Food and Drug Administration has approved only a few psychiatric medications specifically for pediatric use. You might want to keep in mind, however, that few medications used to treat any illnesses— including cancer— have been FDA-approved for children. In many cases, neither pharmaceutical companies nor the government invest in drug trials in children because of the difficulty of finding child participants as well as other reasons.

More information on medications is available at the American Academy of Child and Adolescent Psychiatry’s Parent’s Medication Guide at www.parentsmedguide.org.

A note on physical illnesses and psychiatric treatments

Sooner or later, your child will get sick with a cold, flu, sore throat, or other illness that would normally be treated with an over-the-counter or prescription medication. It is helpful to talk with your psychiatrist or pharmacist ahead of time to find out what potential interactions may exist that could restrict your choices. 

Get information about the use of

  • Pain relievers. Do any of your child’s medications interact with ibuprofen (Motrin, Advil) or acetaminophen (Tylenol)? Are there possible adverse reactions with stronger pain medications, such as codeine or other narcotics (sometimes these can be activating rather than sedating)?
  • Cold and cough medications. In general, it is advisable to avoid the ‘combination’ products that include decongestants, cough suppressants, pain relievers and expectorants in a variety of forms. Again, some of these can be activating or have paradoxical (reverse) effects on children with bipolar disorder.
  • Benadryl. This is often given for relief of itching or to treat hay fever symptoms. 

Find out if any of your child’s mental health medications come in a liquid form. A bad case of strep throat can mean a day or more of missed medications. It helps to know ahead of time what alternatives are available.

Medication—Pediatric Depression

Antidepressant medications are often prescribed for children and teens diagnosed with depression. Although antidepressants are generally considered safe, there is concern that for some individuals under age 25 there may be increased suicide risk, especially in the first few weeks after treatment or when the dosage has changed. Closely monitor your child during this time and report worsening depression, sleeplessness, agitation, or social withdrawal to your child’s doctor. For many teens who experience depression, the benefits of taking antidepressant medication outweigh the risk of harm.

There are several different classes and types of antidepressants to choose from. It is believed that certain brain chemicals, called neurotransmitters, are associated with depression. These brain chemicals include serotonin, norepinephrine and dopamine. Most antidepressants relieve depression symptoms by working on these neurotransmitters. Each class of antidepressant affects these neurotransmitters in slightly different ways. Sometimes stimulants or anti-anxiety medications are prescribed along with anti-depressants.

Medication—Pediatric Bipolar Disorder

Medication is an important consideration for any individual living with bipolar disorder. No one medication works in all children. If medication is included in your child’s treatment plan, consider that it may be a lengthy trial-and-error process as your doctor may have to prescribe several medications, alone or in combination. Two or more mood stabilizers or other medications may be necessary to achieve and maintain the best response.  And it is very common that a medication regimen that works might have to be changed as the child grows and the disorder presents differently.

The major types of medications include the following:

  • Lithium. Lithium can help to reduce symptoms of depression, reduce symptoms of mania, and prevent mood symptoms from returning.
  • Anticonvulsant mood stabilizers. These medications are called anticonvulsants because they were first used to treat epilepsy or convulsions, but they are now used most often to treat bipolar disorder. They can help to reduce symptoms of depression, reduce symptoms of mania, and prevent mood symptoms from returning.
  • Antidepressants. These medications help lift the symptoms of depression. There are several different classes and types of antidepressants to choose from. Antidepressants do not reduce symptoms of mania and can sometimes increase mania or mood swings.
  • Atypical antipsychotics. These medications are called antipsychotics because they were first used to treat schizophrenia, but they are now used most often to treat bipolar disorder. All of these medications can reduce symptoms of mania, and some are also effective for reducing depression.

Psychotherapy

The treatment plan for a child with a mood disorder may include regular therapy sessions with a licensed clinical social worker, a licensed psychologist, or a psychiatrist who provides psychotherapy. Cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, and multi-family support networks are also treatment options to consider for children and adolescents with mood disorders. 

Psychotherapy, like medication, should be tailored to the child and family. Effective therapy can ease symptoms, increase hopefulness, provide healthy coping skills, improve relationships, and improve quality of life. Some improvements should be noted in three to six months.

Types of psychotherapy include:

  • Cognitive behavioral therapy (CBT) which can be an effective way to treat mood disorders.  CBT helps an individual recognize the relationship between their thoughts, feelings and behaviors, to recognize false and negative thoughts (such as “I can never do anything right”), and to change unhealthy ways of thinking or behaving.
  • Dialectical behavior therapy (DBT) is also used to treat adolescents with depression or bipolar disoder, especially when they experience suicidal thoughts or self-harm. DBT helps individuals to accept uncomfortable thoughts, feelings and behaviors and to develop healthy coping skills, including mindfulness practices.
  • Psychodynamic therapy may be used to treat children and adolescents experiencing a mood disorder as well. Psychodynamic therapy is less structured than CBT or DBT and sessions are open-ended and based on what is on the individual’s mind at that time.

Questions to ask about psychotherapy are:

  • What type of therapy is recommended?
  • How will this treatment benefit my child?
  • What are the treatment goals?
  • What skills or coping strategies can my child gain?
  • How often should therapy take place, and about how long should therapy continue?

Some children or teens prefer to meet with a therapist when a parent is in the room. Others talk more openly when alone with the therapist. Family therapy may also be recommended, typically including at least one parent and possibly siblings or other family members. Goals of family therapy are often to improve communication, reduce conflict, teach problem-solving skills, and increase positive interactions.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is safe and effective for children and teens with severe and disabling depression that does not respond to medication or therapy, according the American Academy of Child and Adolescent Psychiatry. As with mediations and other therapies, ask many questions about necessity, other options, and side effects.

ECT uses electricity to stimulate the brain. Patients are put under anesthesia and given a muscle relaxant before treatment.  They often sleep through treatment and do not feel electrical impulses. ECT can cause side effects that are usually short-term, including memory loss, confusion, and disorientation. One year after treatment, most patients have no lasting cognitive effects (NAMI).

Before ECT is used, a full psychiatric assessment must be performed along with a comprehensive physical exam. AACAP states that there is no data suggesting that ECT does harm to the developing brain. However, AACAP recommends every patient considered for ECT have a second independent evaluation by a non-treating psychiatrist to ensure that ECT is needed.

Wellness Strategies

It’s important to remember that many wellness strategies used for adults can help children as well such as relaxation exercises, artistic expression, or journaling. Encourage your child to find activities that help calm them and bring them joy.

One important strategy is getting enough sleep and maintaining regular sleep and wake cycles. This can help children with a mood disorder regain their emotional equilibrium. Consistent bedtimes and good “sleep hygiene” are essential.

Sleep hygiene refers to practices that can foster better sleep, including

  • creating a quiet, dark, cool space for sleep;
  • establishing a soothing pre-sleep routine, such as taking a bath, reading a book, or practicing relaxation exercises such as deep breathing;
  • using the bed for sleep only—not for homework, watching TV, playing video games, or other activities;
  • avoiding substances such as chocolate, tea, and caffeine that can interfere with sleep;
  • avoiding a large meal close to bedtime; a light snack is better if your child is hungry.

Another often overlooked strategy is exercise. Exercise is a natural way to ease depression while improving fitness and overall sense of well-being. Exercise relieves tension and releases soothing endorphins in the brain. To avoid interfering with sleep, strenuous exercise should not occur within one to two hours of a child’s intended bedtime.

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Talking With Your Child About Mood DIsorders

It’s important to talk with your child about his or her mood disorder. Your child may feel frightened, confused, angry, or ashamed. He or she may have encountered stigma or false information from peers or online. Educate yourself about depression or bipolar disorder so that you can offer your child accurate and reassuring information and guidance. Sharing information and inviting questions can encourage your child to bring up concerns in the future.

The best way to talk about depression or bipolar disorder depends on your child’s age and developmental level. Don’t provide more information than your child wants or can handle. Younger children need less information because they have more limited ability to understand. School-age children may want more details. Address their questions directly and honestly and offer support and guidance. Teens typically are ready for more information. Create an open and ongoing conversation so that your child feels able to ask the tough questions he or she may be struggling with.

The American Academy of Child and Adolescent Psychiatry suggests comparing mental health conditions to physical illness. For example, you may explain to a young child that many people get a cold, but fewer people suffer from the more serious ailment of pneumonia. When someone has a cold, they can usually go about their normal activities, but they may take medicine. People who have pneumonia may go to a hospital for treatment, and they also take medicine.

Parents can also explain that it’s normal to sometimes feel sad, angry, anxious, or irritable, but when these feelings are very intense, last for a long time, or interfere with school, friendships, and family relationships, it could be a sign that treatment is needed. Whatever the child’s age and level of maturity, make sure that the conversation takes place when the child or teen feels safe and comfortable. Be alert to his or her reaction. Offer reassurance if your child becomes upset or confused. Return to the conversation later when you child expresses readiness.

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The Impact of a Mood Disorder on the Family

Caring for a child with a mood disorder can have a large impact on the family, including negative effects on siblings or your marriage. It is important to recognize this and take the time to work through family relationship issues. 

Parents or partners may feel guilty, angry, or burned out. They may miss work because of crises at home. Siblings can suffer trauma and the whole family may live in an atmosphere of extended crisis or become isolated. In an exhausting and emotionally overwhelming environment, it is easy to lose track of what “normal” means.

Children and adolescents are often the least prepared to deal with the emotional challenges of living with and caring for a loved one who has a mental health condition. The Mental Health Association of Southeastern Pennsylvania (MHASP) has put together a website than can help children who are having issues growing up with a family member or friend who has a mental health condition. The Sibling Support Project provides resources and support for kids who have a sibling with any sort of disability.

If you have other children, it may be helpful to identify individuals who can care for them during a crisis. There may be times where a child’s behavior (either from rages or severe depression) can be very frightening and unsettling for other children. It is helpful to be able to provide your other children with respite, a break, where they can get away, even for a few hours. Siblings of a child with bipolar disorder or depression may struggle for several reasons:

  • Parents may spend more time focused on and with the child who is experiencing a mental health condition. 
  • Children face the same stigmas surrounding mental illness that we face. 
  • Family plans may be disrupted by the child who is experiencing a mental health condition

When our youngest child was unstable, we focused on her. We took our eyes off her older sister, thinking she would be okay; she was our “rock”. Now, several years later, our “rock” is struggling with her own mood issues. If we hadn’t been so focused on her younger sister, would we have been able to foresee these issues and deal with them? Maybe.

Siblings are affected in ways that can vary with their age and developmental level, whether they feel physically safe, and their own internal resources. Siblings may feel anger toward their brother or sister and they may resent the fact that they cannot bring friends home or enjoy a family outing. They may be afraid of showing negative emotions because they fear losing control like their brother or sister, or they may imitate the behavior of the sibling who lives with a mood disorder. Siblings may be jealous of the attention the child with a mood disorder receives or mourn the family they wish for.

Brothers and sisters often appear highly functional on the surface. But they often hide their struggles to lessen the burden on parents. When their pain emerges, it can be a shock. Short-term coping mechanisms, like repressing anger and refusing to talk about problems, can be unhealthy in the long-term. An experienced therapist can help siblings to accept their feelings and learn healthy coping skills.

Here are some tips to nurture siblings:

  • Don’t allow siblings to take responsibility for the child who is experiencing a mood disorder or for the parents.
  • Let siblings know it is ok to feel angry, jealous, or sad.
  • Watch for signs that siblings are in distress, but be aware that their problems may be hidden.
  • Be available to talk with siblings and to answer questions honestly and in developmentally-appropriate ways.
  • Encourage therapy as a way to gain coping skills and express feelings.
  • Set aside one-on-one time with siblings to share an activity they enjoy.
  • Seek other supports, including sibling support groups.

Marriage and Partnership

Marriages and partnerships can suffer when so much energy is devoted to a child. Often the family becomes isolated and there is little opportunity to spend time as a couple. Parents may feel they are at somehow at fault for their child’s condition. Do your best, but forgive yourself when things don’t go well. Accept that there will be good days and bad days and that some things are out of your control. Express gratitude for the good things in your life.

Here are tips to sustain marriages, partnerships, and families:

  • Make a conscious decision and effort to nurture your partnership; support each other and express appreciation and respect.
  • Consider marriage counseling as part of the process of nurturing your relationship.
  • Engage in “solution thinking;” instead of focusing on what’s wrong, work toward what you want to have happen.
  • Seek balance in your life, so that your child’s issues don’t dominate all the time.
  • Take turns; if one parent or partner is burned out, the other can step in to offer a break.
My husband and I have certainly been pushed to the brink many times since bipolar disorder came into our lives. I think that the stress and strain of the disorder magnifies any other problems or annoyances in a marriage. Stuff that we would otherwise be able to shrug off, or address calmly, becomes much larger and more difficult to work through. I have to say that marriage counseling and therapy have been our saving grace and I highly recommend it. Find a therapist that both you and your spouse feel comfortable with. A really good therapist will not take sides, but will hold each person accountable for their actions. A good therapist will work with you on communication skills and how to identify and reduce the triggers that cause conflict. It’s a lot of hard and often painful work, but well worth the effort.

There is also a book that I found very helpful: Married with Special Needs Children: A Couples’ Guide to Keeping Connected.

Attempt to find strength and peace anyway possible, as you will need an abundance of both.

It’s not the parents' fault.

If someone you trust offers you the chance to get out without the kid(s) TAKE IT!!!! The opportunity is rare. A lot of our children with bp do well when with others and if they don’t, what's the worst that can happen? Even if you have to come home early, at least you got out for a little while.

Mothers seem to bear an additional burden in a family with a child who experiences a mood disorder. Many mothers report that they are the target of much of the child’s rage. The Balanced Mind Parent Network held an expert chat with Dr. Janet Wozniak in January of 2009. Dr. Wozniak is the Director of the Pediatric Bipolar Clinical and Research Program in Pediatric Psychopharmacology at Massachusetts General Hospital. Dr. Wozniak's research focuses on the characteristics and longitudinal course and treatment of pediatric bipolar disorder. Here is an excerpt from that chat where Dr. Wozniak talks about why children living with bipolar disorder take their rage out on mom.

In psychiatry we have neglected the spectrum of irritability. Odd really, as anger is so disabling to individuals and families. But if we hear that someone has an anger problem most clinicians will look to see what the source is.  Anger can occur with depression, bipolar disorder (?), and oppositional/defiant disorder. This last, ODD, is indeed an 'odd' diagnosis because it rarely occurs all on its own but instead is fueled by the impulsivity/frustration of ADHD, the unhappiness of depression, or disinhibition of mania.

One of the contributions from my group in describing and treating children whom we now diagnose as bipolar has been to raise awareness that rage can exist in children; that is, anger is not just typical tantrums or poorly parented children. However, I must say I worry that sometimes I make the point too well that the anger/rage we see is EXTREME and it makes people unnecessarily afraid of these children. Most of the most severe rage occurs at home.

You only need one such episode at school to get kicked out! Or, hopefully, placed in a therapeutic setting. But a lot of the children I see with severe rage at home appear at school to be ADHD-like or depressed-like or anxious-like. They just keep a low profile.

Think of the brain like the way we think of the heart. To bring out the abnormal functioning, we put the person on a treadmill. We give a heart stress test. For most individuals, being at home with our loved ones forming the most intense emotional bonds is our brain's emotional stress test. So no wonder that the most dramatic symptoms occur at home first. Just like for the cardiac patient, the most dramatic symptoms are walking up the hill on the golf course.

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Planning for Safety and Crises

It is important to think about your child’s safety and also the safety of other members of the household. If the child is considered to be a risk to himself or his siblings, hospitalization may be indicated. A child who is not stable is compromised in judgment, self-control, and awareness of the consequences of his or her actions. The ‘fight or flight’ instinct often takes over and a child’s actions may be sudden, reckless, and dangerous. Steps that parents have taken to safeguard the family include

  • locking up any items that could be used to harm self or others;
  • putting a lock on the refrigerator if a child has uncontrolled eating binges;
  • removing window cranks to prevent a child from climbing out bedroom windows (particularly from a higher floor);
  • using the child safety locks on the car ;
  • removing furniture from the bedroom as well as any heavy objects that can be thrown during a rage;
  • putting away all breakables and valuables in the home;
  • locking up all medications so they are out of reach.

You may want to consider training on safe ways to restrain a child. Your child’s psychiatrist or therapist can offer input or refer you to local resources. 

Crisis Planning

Children and teens with mood disorders can become very angry, sad, or even suicidal. It is vital to plan for an emergency before a crisis occurs. Stay calm if your child is in a crisis. It is very scary for a child to feel out of control, and even scarier if adults are also upset. Speak softly and try to help your child to feel safe. 

A crisis situation exists any time your child is no longer safe to himself or to others or when there is a need for immediate action or intervention. It is a time when all of your energies are focused on caring for your child. Some advance planning can make a big difference in getting the care and intervention needed for your child and family.

Many community mental health centers offer crisis help. Find out in advance if your community offers a crisis hotline or crisis intervention assistance. Make sure that these emergency phone numbers are readily accessible in case of an emergency.

Psychiatric Hospitalization

When safety is in question, psychiatric hospitalization is an option. If your child is at risk of harming themselves or others, it is the safest route. Outside of emergencies, hospitalization may be helpful if mood symptoms are getting worse despite appropriate outpatient treatment. It may be tempting to consider hospitalization for rapid medication changes. However, most medications for depression and bipolar disorder work slowly and it takes time to assess whether a change in medication is helpful or not. 

Planning in advance for the possibility of a hospitalization is very important.

  • Talk with your child’s psychiatrist to find out what psychiatric hospital(s) s/he recommends. Your BMPN support community may also have some thoughts for you.
  • Contact the hospital to learn about its inpatient and outpatient programs, the admissions process, policies on visitation, personal belongings, and any other specifics. The more that you know in advance, the less you will have to absorb and learn at a time when you may be upset and distracted. This information will also help you answer your child’s questions about hospitalization.
  • Find out if your child’s psychiatrist provides inpatient care or not and if s/he will coordinate with the inpatient psychiatrists.
  • Check with your insurance company to find out what level of coverage you have and what steps you will need to take to notify them of your child’s hospitalization. Be sure to document all conversations with your insurance carrier and get a first and last name of each person with whom you speak.
  • Determine the level of coverage for both inpatient treatment and day treatment. Some hospitals provide day treatment as a transition after inpatient care. Document carefully and completely. If you are unable to get the necessary information, ask to speak to a supervisor or manager.
  • Keep a folder with a copy of your insurance card, insurance company phone number, and any information you will need for a hospital admission, such as medical history of your child, their medications, and names and contact information for all of your child’s doctors.

Police Intervention

Safety is critical. Call 911 if a situation is out of control and you fear that your child, you, or someone else could be hurt. If you call 911, tell the police dispatcher that your child has bipolar disorder or depression, or if you fear your child could be suicidal. Ask the dispatcher to send a social worker or a police officer with Crisis Intervention Training (CIT), if possible. Depending on the age, size, and strength of your child, as well as the details of the crisis, it may be necessary to call for police assistance in either restraining your child, transporting your child to the hospital, or tracking down a child who has run away.

Before police officers enter your home, tell them that your child has a mental health condition. Let them know, for example, that your child may become upset if someone touches him or her, yells, or stands too close. Work with the police and stay calm. If police or social workers can’t calm your child, tell the police that you want your child to go to a hospital for evaluation and treatment. Tell police that you do not want your child to go to a police lock-up.

Before a crisis occurs, contact your local police department to find out if they have officers who have had CIT training. This program, organized by the National Alliance on Mental Illness, provides training for officers on mental health issues and teaches techniques of de-escalating a crisis. The CIT officers understand the need to take time with an individual: they treat the situation as a case of mental health condition, not criminal activity.

If there is no CIT program in your district, consider talking with your police department in advance of a crisis to make them aware of your child’s condition and the fact that you may need their assistance at some point in the future.

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Education

Your child who lives with a mood disorder has a significant mental health condition that requires ongoing management. Mood disorders and their treatments may have a significant impact on a child's education. The child's functioning may fluctuate throughout the day, the season, and the school year.

The educational needs of a child with a mood disorder vary immensely. Mood disorders and their treatments can affect a child's school attendance, alertness and concentration, sensitivity to light, noise and stress, motivation, and energy available for learning. Transitions to new teachers and new schools, return to school from vacations and absences, and changing to new medications commonly increase symptoms. Medication side effects that can be troublesome at school include increased thirst and urination, excessive sleepiness or agitation, and interference with concentration, weight gain, fatigue, and a tendency to become easily overheated and dehydrated. 
 
A child may need, and is entitled to, the school accommodations necessary to ensure his or her education. The special education staff, parents, and professionals should form a team to determine the child's educational needs. Some families pay for extensive private testing but your public school must provide an evaluation including specialized testing. Specifically request an Individual Education Program (IEP) that identifies the factors that affect the child's education and how they will be accommodated. The IEP should include accommodations for periods when the child is relatively well (when a less intense level of services may suffice) and accommodations available to the child in the event of relapse. A letter from the child's doctor to the director of special education in the school district may be persuasive. Some parents find it helpful to hire an education advocate or necessary to hire a lawyer or to obtain the services that federal law requires public schools to provide for children with health impairments.

Our Working with Educators section will guide you through special considerations in obtaining appropriate education for your child.

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Resources

Please make sure to check our many family resources. For additional resources on mood disorders visit the DBSA Resource Center.

 You may also wish to check out our Glossary of Terms so that you can become well-versed on the acronyms, abbreviations, and other terms often used in the treatment of mood disorders.

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References

Luby J, Belden A. Defining and validating bipolar disorder in the preschool period.  Dev Psychopathol. 2006 Fall;18(4):971-88.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.Washington, DC, American Psychiatric Association, 2000.

Singh MK, Delbello MP, Kowatch RA, Strakowski SM.  Co-occurrence of bipolar and attention-deficit hyperactivity disorders in children.  Bipolar Disord. 2006 Dec;8(6):710-20

Geller B, Tillman R, Craney JL, Bolhofner K.  Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype. Archives of General Psychiatry.  2004 May;61(5):459-67

Geller B, Tillman R, Bolhofner K, Zimerman B, Strauss NA, Kaufmann P. Controlled, blindly rated, direct-interview family study of a prepubertal and early-adolescent bipolar I disorder phenotype: morbid risk, age at onset, and comorbidity. Arch Gen Psychiatry. 2006 Oct;63(10):1130-8.

Birmaher B, Axelson D, Strober M, Gill MK, Valeri S, Chiappetta L, Ryan N, Leonard H, Hunt J, Iyengar S, Keller M. Clinical course of children and adolescents with bipolar spectrum disorders. Archives of General Psychiatry. 2006 Feb;63(2):175-83.

National Institute of Mental Health, Web site accessed July 3, 2007:http://www.nimh.nih.gov/science-news/2006/largest-study-to-date-on-pediatric-bipolar-disorder-describes-disease-characteristics-and-short-term-outcomes.shtml

McGuffin P, Rijsdijk F, Andrew M, et al.  The heritability of bipolar affective disorder and the genetic relationship to unipolar depression.  Arch Gen Psychiatry. 2003 May;60(5):497-502.

Carmen Moreno; Gonzalo Laje; Carlos Blanco; Huiping Jiang; Andrew B. Schmidt; Mark Olfson Arch Gen Psychiatry. 2007;64:1032-1039

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