This is the slide set to the lectures I provided to the medical staff of Child and Adolescent Behavioral Health in Canton, OH during the Fall-Winter of 2018
Depression In Children: Behavioral Manifestations and InterventionDavid Songco
Presentation delivered to the West Side Health Authority. This presentation was attended by program developers, teachers, principals, and directors of local community organizations.
This is a project for a high school AP psychology course. This is a fictionalized account of having a psychological ailment. For questions about this blog project or it’s content please email the teacher Chris Jocham: jocham@fultonschools.org.
Depression In Children: Behavioral Manifestations and InterventionDavid Songco
Presentation delivered to the West Side Health Authority. This presentation was attended by program developers, teachers, principals, and directors of local community organizations.
This is a project for a high school AP psychology course. This is a fictionalized account of having a psychological ailment. For questions about this blog project or it’s content please email the teacher Chris Jocham: jocham@fultonschools.org.
This presentation is about geriatric Psychiatry awareness. it contains basic information about what is geriatric psychiatry, which are the main psychiatry disorder found in elderly and how to manage them?. it contains some detailed information about late life depression, delirium and dementia in geriatric population.
Evaluation and Treatment of Anxiety Disorders in Children and TeensStephen Grcevich, MD
This presentation will familiarize prescribers with signs, symptoms of anxiety disorders in children and teens, examine pivotal studies comparing the impacts of medication vs. psychotherapy in treatment of kids with anxiety, compare the benefits and risks of FDA-approved and “off-label” medications used to treat pediatric anxiety disorders and explore recent data comparing advantages, disadvantages of specific SSRIs used to treat anxiety in children, teens
Module: Pharmacotherapy III
Module Coordinator: Dr. Arwa M. Amin Mostafa
Academic Level: Postgraduate, Master of Pharmacy in Clinical Pharmacy
School: Dubai Pharmacy College
Year of first presented in Class: 2018
This presentation is for Educational purpose. It has no commercial value associated with it.
Introduction to Depressive Disorders in Children and AdolescentsStephen Grcevich, MD
These slides accompany the didactic lectures Dr. Stephen Grcevich presented to child and adolescent psychiatry fellows at Akron Children's Hospital in September 2020. Topics covered include:
Session One: Epidemiology, presentation throughout childhood/adolescence, clinical course, risk factors, etiology
Session Two: Evaluation – diagnostic criteria, differential diagnosis, comorbidity, use of rating scales
Session Three: Pharmacotherapy and other medical treatments
Session Four: Non-pharmacologic treatments
This presentation is about geriatric Psychiatry awareness. it contains basic information about what is geriatric psychiatry, which are the main psychiatry disorder found in elderly and how to manage them?. it contains some detailed information about late life depression, delirium and dementia in geriatric population.
Evaluation and Treatment of Anxiety Disorders in Children and TeensStephen Grcevich, MD
This presentation will familiarize prescribers with signs, symptoms of anxiety disorders in children and teens, examine pivotal studies comparing the impacts of medication vs. psychotherapy in treatment of kids with anxiety, compare the benefits and risks of FDA-approved and “off-label” medications used to treat pediatric anxiety disorders and explore recent data comparing advantages, disadvantages of specific SSRIs used to treat anxiety in children, teens
Module: Pharmacotherapy III
Module Coordinator: Dr. Arwa M. Amin Mostafa
Academic Level: Postgraduate, Master of Pharmacy in Clinical Pharmacy
School: Dubai Pharmacy College
Year of first presented in Class: 2018
This presentation is for Educational purpose. It has no commercial value associated with it.
Introduction to Depressive Disorders in Children and AdolescentsStephen Grcevich, MD
These slides accompany the didactic lectures Dr. Stephen Grcevich presented to child and adolescent psychiatry fellows at Akron Children's Hospital in September 2020. Topics covered include:
Session One: Epidemiology, presentation throughout childhood/adolescence, clinical course, risk factors, etiology
Session Two: Evaluation – diagnostic criteria, differential diagnosis, comorbidity, use of rating scales
Session Three: Pharmacotherapy and other medical treatments
Session Four: Non-pharmacologic treatments
Evaluation and Treatment of Bipolar and Related Disorders in Children and Ado...Stephen Grcevich, MD
In these lectures presented by Dr. Stephen Grcevich to child and adolescent psychiatry trainees at Akron Children's Hospital in January 2021, the following objectives were addressed:
Identify critical questions challenging our assumptions regarding treatment of bipolar disorder in kids.
Explore diagnostic challenges associated with comorbidity with other common mental health conditions.
Review key literature evaluating effective pharmacotherapy of pediatric bipolar disorder.
Examine available data on non-pharmacologic treatments in kids with bipolar disorder.
CONDITION OF ADHD: AND HOW WITHOUT SEAMLESS TRANSITION INTO ADULT CLINICS AFFECTS ADULT LIFE OUTCOMES & HOW IT COULD BE PROPERLY FACILITATED HAVING CREATED AND SUCCESSFULLY CONDUCTED ONE FOR TWO YEARS - PRESENTED AT A UNITED KINGDOM NATIONAL CONFERENCE
Children are at high risk of emotional disorders. These have become the most common reasons for their visits to the psychiatrist.
They include mood disorders, anxiety disorders, and trauma and stress-related disorders.
This slide explains each of these in details.
Enjoy
“Teen Depression and Suicide,”
South Portland, Maine; April 26, 2005
Suicide Conference, Maine Suicide Prevention Program.
*Learn clinical presentation of adolescent depression
*Learn course and prognosis of pediatric depression
*Learn treatment of pediatric depression
*Discuss controversy of antidepressant medications in youth and suicidality
This poster was presented to highlight the following mental health conditions in adolescent patients: attention deficit/hyperactivity disorder (ADD/ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD).
Mental Health is a very important aspect of public health. Although mental health assessment is vital within all populations, it is especially vital to assess mental health within our vulnerable populations (e.g. adolescents)
Definition of mental health
Describe the problem statement
List the characteristics of a mentally healthy person
List the warning Signals of Poor Mental Health
Classify mental illness
Enumerate the causes of mental ill-health
Discuss the consequences of poor mental health
Explain about the Mental Health Services
Epidemiology of Alcoholism and Drug Dependence
Describe the Symptoms of drug addiction
Prevention, treatment, and rehabilitation for drug dependence
When is World Mental Health Day
Similar to Introduction to Depressive Disorders in Children and Adolescents (20)
Slides from Lunch and Learn Lectures by Stephen Grcevich, MD, sponsored by Stark County MHAR Board, August 2023.
Videos may be found here:
https://vimeo.com/853034484
https://vimeo.com/856856675
https://vimeo.com/863669380
Helping Patients Through ADHD Medication Shortages and Discontinuation Grcevi...Stephen Grcevich, MD
In this presentation, Dr. Stephen Grcevich will identify reasons for current shortages of immediate and extended-release Adderall, examine implications of the “authorized” Concerta generic being discontinued in January 2023 and discuss treatment options for patients who are unable to access ADHD medications on which they have been stabilized.
Understanding DMDDTreating kids with protracted anger outbursts and irritabi...Stephen Grcevich, MD
Learning Objectives:
Examine why DMDD was established as a stand-alone diagnosis in DSM-5, review the diagnostic criteria for DMDD, along with the differential diagnosis from other common conditions and explore what we know about treating kids with DMDD
Participants will explore the prevalence of psychotic experiences among kids with mental health concerns and kids in the general population, discuss the differential diagnosis of psychotic symptoms in children and youth, examine the relationship between hallucinations and suicidal behavior in youth and review the appropriate psychiatric and medical workup for youth with psychotic experiences
Grcevich Thoughtful Child Psychopharmacology in the Summer.pptxStephen Grcevich, MD
Participants will explore a model for medical decision-making in adjusting medication regimens in children and teens being treated for common mental health conditions during the summertime, identify issues and concerns unique to summer that may impact prescribing decisions and explore the rationale for “structured treatment interruptions” of pharmacotherapy during the summer, with a focus on medication for ADHD
Dr. Steve Grcevich's slide set from event hosted by the student ministry staff at Cuyahoga Valley Church, Broadview Heights Campus. The slide set addresses questions regarding the impact of COVID on teen mental health, possible causes for the increased rates of mental health disorders reported in this population, signs of anxiety and depression, and eleven simple signs of kids experiencing mental health struggles.
In this presentation, Dr. Steve Grcevich will...
Explore the rationale for regular consideration of deprescribing in children, teens and adults with mental health conditions.
Examine the indications for deprescribing in individual patients.
Consider a process for simplifying complex medication regimens in patients with suboptimal therapeutic benefits and/or unacceptable adverse effects.
Dr. Steve Grcevich's presentation for the suicide prevention webinar offered by Community Health Center of Northeast Oklahoma, March 10, 2021. The presentation includes a series of action steps for pastors and clergy of all faiths to follow to be prepared to respond to attendees with suicidal thoughts, plans or behavior .
Mental Health in a Time of COVID-19: Preparing Faith and Community PartnersStephen Grcevich, MD
Key Ministry’s President & Founder, Dr. Steve Grcevich, co-presented with Kay Warren and former congressman Dr. Tim Murphy for this webinar from the U.S. Department of Health and Human Services. The aim was to help churches and religious leaders of all faiths respond to #mentalhealth support needs arising from #COVID19. Link to video: https://youtu.be/C8Zzgw4ihOg
Including Students with Common Mental Health Conditions at ChurchStephen Grcevich, MD
In this presentation from the 2020 Together Conference, Dr. Grcevich reviews research demonstrating the need for an intentional approach to mental health inclusion at church,
recognizes common barriers to inclusion at church for children, teens and adults with common mental health conditions, explores how a set of mental health inclusion strategies might be applied to potential obstacles in your church and identifies five attributes of a mental health-friendly church
Overcoming Challenges to Spiritual Growth in Children and Teens with ADHDStephen Grcevich, MD
In this presentation from the Together Conference at Mount Paran Church, Dr. Grcevich reviews:
Brain functioning associated with ADHD
Impacts of ADHD upon worship service attendance and involvement in Christian education and other church activities
ADHD inclusion strategies across ministry environments
Common pitfalls to spiritual development for children, teens and adults with ADHD
Practical ideas family members can use to promote spiritual growth in their child, spouse or loved one with ADHD
Neuropsychiatric disorders are the leading cause of disability among persons of all ages in the U.S., and common mental health conditions such as depression, anxiety disorders and ADHD have been demonstrated to significantly impact church attendance. This workshop is designed for any church, pastor, ministry leader, staff member or volunteer interested in becoming more intentional in their outreach to and inclusion of families impacted by mental illness. Participants will be taught to recognize common barriers to church participation for children and adults with common mental health conditions, introduced to a series of strategies for including persons with mental illness into the full range of ministry activities offered by the local church and provided with the resources necessary to initiate a mental health ministry planning process. This is a 3 hour workshop divided into 2 parts.
Recent research from Clemson University demonstrates that families of children and teens with mental health conditions such as depression, anxiety, ADHD, Oppositional Defiant Disorder and Conduct Disorder are significantly less likely than their neighbors to never attend church. In this talk, Dr. Grcevich will outline some basic steps every church can take to minister more effectively with individuals and families impacted by mental illness.
ADHD affects approximately one in ten children and one in twenty adults in the U.S. Children and teens with ADHD and members of their immediate families are significantly less likely to ever set foot in a church. In this workshop of interest to ministry leaders, family members and professionals, Dr. Stephen Grcevich will discuss the differences in brain functioning seen in persons with ADHD, explain how the condition impacts participation in worship services, Christian education and other common church activities, identify common pitfalls to spiritual development, share useful strategies for including persons with ADHD into church programming and provide practical ideas family members can use to promote spiritual growth in their child, spouse or loved one with ADHD.
Why Families of Kids With Mental Illness Don’t Attend Church - And How Counse...Stephen Grcevich, MD
In this presentation from the 2019 American Association of Christian Counselors National Conference Dr. Grcevich examines the relationship between the presence of mental health conditions in children and adolescents and family church attendance, reviews seven common barriers to church attendance and ministry participation for families of children with common mental health disorders and introduces a range of approaches counselors might employ in supporting clients with church participation and churches in their ministry with families impacted by mental illness.
Evaluation and Treatment of Children and Adolescents With Sleep DisordersStephen Grcevich, MD
In this presentation from Child and Adolescent Behavior Health in Canton OH, Dr. Stephen Grcevich discusses evaluation and treatment of insomnia in children and teens in an outpatient psychiatric treatment setting. Viewers will review guidelines describing “normal” sleep in children and teens, explore common causes of sleep disturbance in the pediatric population, address treatment of sleep issues associated with common psychiatric conditions in children and teens and be presented with an approach to addressing concerns with insomnia in clinical practice.
Link to video: https://www.slideshare.net/drgrcevich/evaluation-and-treatment-of-children-and-adolescents-with-sleep-disorders
In this keynote presentation from Inclusion Fusion Live 2019, Dr. Steve Grcevich discusses recent research on the relationship between mental illness and church attendance, and encourages churches to adopt an intentional strategy for welcoming and including families impacted by mental illness. i
It's the Mental Health Disabilities That Keep Kids Out of ChurchStephen Grcevich, MD
Dr. Steve Grcevich's presentation from the Together Special Needs Conference at Mount Paran Church examines research on the association between common disabilities and church attendance in children and teens, identifies seven common barriers to church attendance for families impacted by mental illness and introduces a model for mental health ministry applicable to churches of all sizes and denominations.
Helping Churches Support Individuals and Families Affected by Mental IllnessStephen Grcevich, MD
In this presentation sponsored by the Stark County Mental Health and Addiction Recovery Board, Dr. Grcevich addresses potential areas of collaboration between churches and mental health/social service providers in serving families impacted by mental illness and discusses ways in which mental health professionals and support staff can advocate for inclusion of persons with mental illness within their places of worship.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Introduction to Depressive Disorders in Children and Adolescents
1. Introduction to Depressive Disorders in Children and
Adolescents
Stephen Grcevich, MD
Clinical Associate Professor of Psychiatry, NEOMED
Presented at Child and Adolescent Behavioral Health
November 2018 – January 2019
2. Overview of the course…
• Epidemiology, presentation throughout
childhood/adolescence, clinical course, risk factors,
etiology
• Evaluation – diagnostic criteria, differential
diagnosis, comorbidity, use of rating scales
• Pharmacotherapy and other medical treatments
• Non-pharmacologic treatments
3. What do we know about
depression in children, teens?
• Why do kids get depressed?
• How many kids/families are affected?
• What’s the impact on kids developmentally?
4. Question 1
A prepubertal child with a diagnosis of MDD is
most likely to have which of the following
symptoms…
• A-auditory hallucinations
• B-paranoid delusions
• C-drug abuse
• D-rosy glow
• E-all of the above
5. Question 2
• A teenager with MDD is NOT likely to have
which of the following symptoms
• A-Hypersomnia
• B-Overeating
• C-Delusions
• D-Separation Anxiety Disorder
• E-Suicidal ideation
6. Question 3
Which of the following predicts recurrence of
MDD in youth?
• A-Later age at onset
• B-Decreased number of prior episodes
• C-Psychosis
• D-Intelligence
• E- All of the above
7. Question 4
Which of the following increases likelihood of
bipolar disorder in youth with MDD?
• A-Comorbid ADHD
• B- Psychomotor agitation
• C-Comorbid anxiety disorder
• D-Family history of non-psychotic depression
• E-Heavy familial loading for mood disorders
8. Question 5
Which statement best characterizes Persistent
Depressive Disorder in youth?
• A-Not associated with increased risk of MDD
• B-10% of youth with Dysthymia have MDD
• C-Dysthymia has mean episode of 3-4 years for
clinical & community samples
• D-First MDD episode usually occurs 10 years
after onset of Dysthymia,
• E-None of the above
10. What is depression?
• A condition resulting from disordered capacity for
emotional self-regulation
• Mediated by interconnections between prefrontal cortex
and limbic system
• Exaggerated activation of amygdala in adolescents in
response to emotional cues, under-recruitment of
prefrontal cortex
• Multiple neurotransmitter systems involved
• The role of serotonin in inhibiting and opposing the
effects of dopamine, especially in terms of impulsive and
aggressive behavior
11. MDD Diagnostic Criteria:
DSM-5
• At least 2 weeks of pervasive change in mood manifest
by either depressed or irritable mood and/or loss of
interest and pleasure.
• Other symptoms: changes in appetite, weight, sleep,
activity, concentration or indecisiveness, energy, self-
esteem (worthless, excessive guilt), motivation, recurrent
suicidal ideation or acts.
• Symptoms produce clinically significant distress or
impairment
• Symptoms not attributable to substance abuse,
medications, other psychiatric illness, medical illness
12. Epidemiology
• MDD prevalence: 2% children, 4%-8%
adolescents
• Male/female ratio:
• Childhood 1:1
• Adolescence 1:2
• Cumulative incidence by age 18 years: 20%
• Each successive generation at higher risk for
MDD since 1940
• Persistent Depressive Disorder prevalence: 0.6%-
1.7% children, 1.6%-8% adolescents
13. National Comorbidity Survey
• Nationwide study of 10K+ adolescents for MDD
• Lifetime prevalence: 11%, 12-month prevalence 7.5%
• “Severe MDD” (2-5X greater functional impairment) in
¼ of total MDD cases
• 60% receive treatment
• Most treatment isn’t diagnosis-specific
• Most treatment isn’t delivered by mental health
professionals
Avenovili et al. J Am Acad Child Adolesc Psychiatry 2015;52(1)37-44.e2
14. Developmental Variations of
Depression
CHILDREN:
• More symptoms of anxiety
(i.e. phobias, separation
anxiety), somatic
complaints, auditory
hallucinations
• Express irritability with
temper tantrums & behavior
problems
• Fewer delusions, serious
suicide attempts
• Prepubertal onset related to
conduct disorder, impulsive
aggression
ADOLESCENTS:
• More sleep and appetite
disturbances, delusions,
suicidal ideation & acts,
impairment of
functioning
• Compared to adults,
more behavioral
problems, fewer
neurovegetative
symptoms
15. How does the clinical presentation of
depression differ with age?
Goldman S. Child Adolesc Psychiatric Clin N Am 21 (2012) 217-235.
16. Clinical Course of Depression:
• Median Duration:
Clinically referred youth: 7-
9 months
Community youth: 1-2
months
• Predictors of longer
duration: depression
severity, comorbidity,
negative life events,
parental psychiatric
disorders, poor
psychosocial functioning
• Remission defined as a
period of 2 weeks to 2
months with 1 clinically
significant symptom
• Recovery defined as an
asymptomatic period
lasting at least two months
• 90% MDD episodes remit
1-2 years after onset
• 6%-10% MDD are
protracted
17. Relapse
• Relapse is an episode of MDD during period of
remission
• Predictors of relapse: Natural course of MDD, lack of
treatment adherence, negative life events, rapid
decrease or discontinuation of therapy
• 40%-60% youth with MDD relapse after successful
acute therapy
• Relapse may indicate a need for continuous treatment
18. Recurrence
• Defined as emergence of
MDD symptoms during
recovery (asymptomatic
period of more than 2
months)
• Probability of recurrence
• 20%-60% within 1-2
years of remission,
• 70% after 5 years
Predictors:
• Earlier age at onset
• Increased number of prior
episodes
• Severity of initial episode
• Psychosis
• Psychosocial stressors
• Dysthymia & other
comorbidity
• Lack of adherence to
therapy
19. Risk of Bipolar Disorder in Kids
with Major Depression
20%-40% MDD youth develop bipolar disorder in 5 years of onset of
MDD
Predictors of Bipolar I Disorder Onset:
• Early onset MDD
• Psychomotor retardation
• Psychosis
• Family history of psychotic depression
• Heavy familial loading for mood disorders
• Pharmacologically induced hypomania
20. Risk factors for depression
• Family history
• Prior experience of
depression
• Negative cognitive
style
• Bereavement
• Poverty
• Exposure to violence
• Life stressors
• Social isolation
Specific risk factors
Non-specific risk
factors
Beardslee WR et al. Child Adolesc Psychiatric Clin N Am 21 (2012) 261-278.
21. Sources of biological vulnerability
• Transporter genes (gene x environment pathway)
• HPA axis
• Affective and vagal tone
• Cerebral variations (form and development)
• Cognitive style
• Influence of hormones during puberty
• Neurophysiologic/neurocognitive changes of
adolescence
22. Neuroimaging Findings:
• Cortical thinning as possible endophenotype of early-onset
depression (Peterson & Weissman, 2011)
• Decreased hippocampal volume (Rao, 2009)
• Increased amygdala activation (Yang, 2010)
• Decreased regional cerebral blood flow…(Ho et al., 2013)
23. Neuroimaging findings in
females…
• Smaller nucleus accumbens volume
• Increased growth of amygdala from early to
mid-adolescence
Whittle S et al. Am J Psychiatry. 2014 May;171(5):564-71.
24. Genetic Factors
• Children with depressed parent 3x likely to
have lifetime episode of MDD (lifetime risk
15%-60%)
• Concordance rates of 40-65% in monozygotic
twins
• Prevalence of MDD in first-degree relative of
children with MDD is 30%-50% (parents of
MDD children also have anxiety, substance
abuse, personality disorders)
25. Epigenetic Factors
• Epigenetic changes in ID3, GRIN1, and TPPP genes in combination
with experiences of maltreatment may confer risk for depression in
children.
• ID3 involved in the stress response, GRIN1 involved in neural
plasticity, and TPPP involved in neural circuitry development.
• Short allele of serotonin transporter gene-linked polymorphism
region (5HTTLPR) associated with increased risk of depression only
if they experienced severe maltreatment in childhood
• Other candidate genes – Corticotrophin releasing hormone Type 1
receptor (CRHR1) and brain-derived neurotrophic factor gene
(BDNF)
• Epigenetic changes are frequently long lasting, but not necessarily
permanent
Weder et al. J Am Acad Child Adolesc Psychiatry 2014;53(4)417-24.e5
26. Summary of contributing factors to course
of childhood, adolescent depression
• 2-4X increased risk after puberty, especially in girls
• Poor school success, learning problems, comorbid psychiatric
disorders that interfere with learning
• Genetic & environmental factors
• Non-shared intrafamilial & extrafamilial environmental experiences (how
individual parents treat each child)
• Kids at high genetic risk more sensitive to adverse environmental effects
• Personality traits: judgmental, anger, low self-esteem, dependency
• Cognitive style & temperament: negative attributional styles
• Adverse childhood experiences (ACE)
• Recent adverse events
• Conflictual family relations
• Neglect, abuse
28. Depressive Disorders in Children and Adolescents
Issues in Evaluation and Diagnosis
• Stephen Grcevich, MD
• Clinical Assistant Professor of Psychiatry, NEOMED
• Presented at Children’s Hospital Medical Center of Akron
• February, 2018
29. Topics to be covered today:
• Diagnostic criteria for depressive disorders seen in
children and teens
• Differential diagnosis of depression
• Common comorbidities associated with pediatric
depression
• Use of rating scales in assessment
• Depressive disorder modifiers in DSM-5
• DMDD as a depressive disorder?
30. How do you diagnose
depression?
• What signs, symptoms are you looking for in your
interviews with child/parent/caregiver?
• Do you use rating scales? If so, how much weight
do you place on the results?
• How do you differentiate depression from “normal”
response to living in dysfunctional environments?
31. MDD Diagnostic Criteria:
DSM-5
• At least 2 weeks of pervasive change in mood manifest
by either depressed or irritable mood and/or loss of
interest and pleasure.
• Other symptoms: changes in appetite, weight, sleep,
activity, concentration or indecisiveness, energy, self-
esteem (worthless, excessive guilt), motivation, recurrent
suicidal ideation or acts.
• Symptoms produce clinically significant distress or
impairment
• Symptoms not attributable to substance abuse,
medications, other psychiatric illness, medical illness
32. Differential Diagnosis of MDD
in Children, Teens
• Anxiety disorders, OCD
• DMDD
• Bipolar disorder
• Learning disabilities
• ADHD, disruptive behavior disorders
• Personality disorders (Borderline PD)
• Substance use disorders
• Adjustment disorder with depressed mood
• Medical causes (including medication)
33. Differential Diagnosis:
Complexities of General Medical
Conditions
• May be accompanied by symptoms of depression
• Impact course of depressive disorder
• MDD can be diagnosed if depressive symptoms
preceded or not solely due to medical illness or
medications to treat medical illness
• Incidence of MDD higher in certain medical illnesses
• Chronic illness may affect sleep, appetite, energy
• Guilt, worthlessness, hopelessness, suicidal ideation
usually not attributed to medical illness but suggest MDD
34. Medical conditions associated
with depressive symptoms
• Cancer, hypothyroidism, lupus, acquired
immunodeficiency syndrome, anemia, diabetes,
epilepsy
• Chronic Fatigue Syndrome: symptoms similar to
MDD but with more somatic symptoms, less
mood, cognitive, social symptoms
• Medication induced symptoms: stimulants,
neuroleptics, corticosteroids, contraceptives
35. Comorbidity
• Present in 40%-90% of youth with MDD; two or more
comorbid disorders present in 20%-50%
• Comorbidity in youth with MDD: Dysthymia or anxiety
disorders (30%-80%), disruptive disorders (10-80%),
substance abuse disorders (20%-30%)
• MDD onset after comorbid disorders, except for
substance abuse
• Conduct problems: May be a complication of MDD &
persist after MDD episode resolves
• Anxiety: Children manifest separation anxiety;
adolescents manifest social phobia, GAD, conduct
disorder, substance abuse
36. Diagnostic Complexities
• Overlap of mood disorder symptoms
• Symptoms overlap with comorbid disorders
• Developmental variations in symptom
manifestations
• Etiological variations of mood disorders involving
gene-environment interactions
• Spectrum or categorical disorders?
• Effects of medical conditions?
37. Rating Scales for Depression
• Children’s Depression Inventory (CDI 2)
• Beck Depression Inventory (BDI-II)
• Rating scales in public domain…
• Columbia Depression Scale
• PHQ-9 (teen version)
• Center for Epidemiological Studies Depression Scale
for Children (CES-DC)
Link for scales in public domain:
https://candapediatricmedicalhomes.wordpress.com/child-
psychiatry-rating-scales-for-primary-care-physicians/
38. Children’s Depression
Inventory
• Originally derived from BDI
• 27 item, self-report scale used in children ages 7-17
• Each item scored on 0-2 scale
• 20 - typical cutoff score for depression, scores of 36
or higher suggest severe depression
• Examines five factor areas…
• Negative Mood
• Interpersonal Problems
• Ineffectiveness
• Anhedonia
• Negative Self Esteem
39. Beck Depression Inventory
(BDI-II)
• 21 item, self-report scale
• Designed for individuals ages 13 and up
• Patient asked to evaluate symptoms over the
last two weeks
• Each item scored on a 0-3 scale
• 0–13: minimal depression
• 14–19: mild depression
• 20–28: moderate depression
• 29–63: severe depression.
40. Advantages and disadvantages
of rating scales…
• Advantages:
• May help guide treatment decision-making
• Provides a tool for measuring treatment response
• Kids may respond differently to questions presented
on rating scale vs. clinical interview
• Disadvantages:
• Should we assume kids understand the questions?
• Are we measuring distress (or something else) as
opposed to depression?
• Are we treating a score instead of the kid?
41. Distinguishing bereavement from
depression in the DSM-5
• Painful feelings often come in
waves, intermixed with
positive memories of the
deceased
• Self-esteem usually preserved
• A stressor that may precipitate
depression
• Mood and ideation is almost
constantly negative
• Corrosive feelings of
worthlessness, self-loathing
are common
• Should not be diagnosed in
the context of typical
bereavement
Grief Depression
American Psychiatric Association, 2013
42. Persistent Depressive Disorder
(Dysthymia) DSM-5 Criteria:
• Persistent, long-term change in mood, less
intense but more chronic than MDD
• Depressed mood on most days for most of the
day for at least 1 year (2 years in adults)
• At least 2 other symptoms: appetite, sleep, low
energy/fatigue, low self-esteem, poor
concentration or difficulty with decision-making,
hopelessness
• Person is not without symptoms for more than
2 months at a time and has not had MDD for
the first year of disturbance; never had manic
or hypomanic episode
43. Clinical Course: Relation of
Persistent Depressive Disorder
• Associated with increased risk of MDD
• 70% of youth with Persistent Depressive Disorder have
MDD
• Persistent Depressive Disorder has mean episode of
3-4 years for clinical & community samples
• First MDD episode usually occurs 2-3 years after onset
of Persistent Depressive Disorder, gateway to
recurrent MDD
• Risk for Persistent Depressive Disorder: chaotic
families, high family loading for mood disorders,
particularly Persistent Depressive Disorder
44. DSM-5 Depressive Disorder Modifiers
Suggest Need for Alternate Intervention
Strategies
• Anxious Distress
• Mixed features (mania, hypomania)
• Melancholic features
• Atypical features
• Psychotic features
• Catatonia
• Peripartum onset
• Seasonal pattern
45. Depressive disorder modifiers
in DSM-5: Anxious Distress
At least two of the following symptoms during the majority of
days of a major depressive or persistent depressive
episode)…
• Keyed up/tense,
• Unusually restless,
• Difficulty concentrating because of worry,
• Fear something awful may happen,
• Feeling the individual might lose control of himself, herself
Severity specified as mild (two symptoms) moderate (three
symptoms) moderate-severe (four or five symptoms) severe
(four of five symptoms PLUS motor agitation)
46. MDD with psychotic features
• MDD associated with mood congruent or incongruent
hallucinations and/or delusions (unlike adolescents, children
manifest mostly hallucinations)
• Occurs in up to 30% of those with MDD
Is associated with…
• more severe depression,
• greater long-term morbidity,
• resistance to antidepressant monotherapy,
• low placebo response,
• increased risk of bipolar disorder
• family history of bipolar and psychotic depression
47. Depressive disorder modifiers
in DSM-5: Mixed Features
At least three of the following manic/hypomanic symptoms during the
majority of days of a major depressive episode
• Elevated, expansive mood
• Inflated self-esteem, grandiosity
• More talkative than usual, pressure to keep talking
• Flight of ideas or subjective experience that thoughts are racing
• Increase in energy or goal-directed activity
• Increased, excessive involvement in activities with potential for painful
consequences
• Decreased need for sleep
Diagnosis should be Bipolar I or Bipolar II disorder for patients who meet
criteria for those conditions
48. Depressive disorder modifiers
in DSM-5: Melancholic Features
Loss of pleasure in all, or almost all activities, or lack of
reactivity to usually pleasurable stimuli, including three or
more of the following:
• Distinct quality of depressed mood characterized by
profound despondency, despair, moroseness, or “empty
mood”
• Depression worse in the morning
• Early AM awakening (at least two hours before usual time)
• Marked psychomotor agitation or retardation
• Significant anorexia or weight loss
• Excessive or inappropriate guilt
49. Depressive disorder modifiers
in DSM-5: Atypical Features
These features predominate during the majority of days of a
major depressive episode
• Mood reactivity (brightens in response to actual or potential
positive events and two or more of the following
• Significant weight gain or increase in appetite
• Hypersomnia
• Leaden paralysis (heavy, leaden feelings in arms, legs)
• Longstanding pattern of interpersonal rejection sensitivity
Criteria not met for melancholic features or catatonia within
that depressive episode
50. Depressive disorder modifiers
in DSM-5: Psychotic Features
Delusions and/or hallucinations are present
• Mood-congruent psychotic features
• Mood-incongruent psychotic features
51. Depressive disorder modifiers
in DSM-5: Seasonal pattern
This specifier applies to recurrent Major Depressive
Disorder…
• Regular temporal relationship between onset of MDD
episodes and time of year (Fall, Winter)
• Full remission (or switch to mania/hypomania) often occurs
in Spring
• Two MDD episodes in ;last two years with NO non-seasonal
episodes of MDD
• Seasonal episodes of MDD outnumber non-seasonal MDD
episodes throughout the patient’s lifetime.
52. What about Disruptive Mood
Dysregulation Disorder?
There’s a large group of kids who demonstrate…
• Irritability as their predominant mood state
• Problems with emotional self-regulation frequently
leading to aggression
• Difficulties with attention, concentration, academic
performance
• “At-risk” behaviors…self injury, substance use, suicidal
behaviors
53. DSM-5 criteria for Disruptive Mood
Dysregulation Disorder (DMDD):
• A. Severe, recurrent temper outbursts manifested verbally (rages) and/or behaviorally (physical
aggression to people, property) grossly out of proportion in intensity or duration to the
situation/provocation
• B. Temper outbursts inconsistent with developmental level
• C. Temper outbursts occur, on average, 3X or more/week
• D. Mood between outbursts persistently irritable or angry, observable to others
• E. Above four criteria present for 12+ months, with no more than three months symptom-free
• F. A and D criteria present in at least two of three settings (home, school, peers), severe in at least
one setting
• G. Initial diagnosis not made in children under 6 or over 18
• H. Age of onset prior to age 10
• I. No distinct period >1 day where criteria for mania, hypomania met
• J. Doesn’t occur exclusively during MDD episode, not better explained by another mental disorder
(ASD, PTSD, Separation Anxiety Disorder, Persistent Depressive Disorder)…can’t coexist with
ODD, Bipolar Disorder, Intermittent Explosive Disorder
• K. Not attributable to substance use, another medical, neurologic condition
54. What do kids with DMDD look like?
• Most have ADHD (86.3%) and ODD (84.2%)
• 60% at NIMH were diagnosed in community with bipolar
disorder
• They have a higher than expected prevalence of lifetime
anxiety disorders (58.2%) and lifetime major depression
(16.4%)
• Seven times more likely to be depressed at age 18
• Chronic irritability in adolescence predicts MDD, GAD
and dysthymia at age 33
Leibenluft E. Am J Psychiatry 2011; 168(2):129-42
55. What I’ve observed about kids
with DMDD…
• They have difficulty with transitions…”cognitive rigidity”
• They tend to “ruminate”…indecisive, think too much
about things, perseverate
• They may experience some improvement in some
settings from ADHD medication, but become more
irritable, have more meltdowns at home on medication
• They do better when they’re busy…inactivity increases
irritability
• They’re prone to behavioral activation on SSRIs that is
often mistaken for mania, hypomania
56. How I’m treating DMDD…
• Conservative use of ADHD medication…limited as much as
possible to school day
• Meltdowns related to perseverative frustration with inability
to achieve desired outcomes may respond to SSRIs,
clomipramine
• Behavioral activation from SSRIs appears dose-
dependent…titrate weekly in small increments
• Lots of CBT! Kids need strategies to help manage
perseverative thinking
• Aggressively dosing accommodations, school-based
interventions
• SGAs as last resort for severe aggression (risperidone)
57. Summary: MDD in Children &
Adolescents
• Diagnostic criteria similar for depression in children
and adults, although clinical presentation may differ
• Differential diagnosis is extensive and complex,
requiring careful evaluation
• Comorbidity is probably the norm as opposed to the
exception
• Rating scales may be useful tools in evaluation,
measuring response to treatment
• Kids who meet diagnostic criteria for DMDD at higher
risk of MDD as they progress into adulthood
58. Biological Treatment of Depression in Children and
Adolescents
Stephen Grcevich, MD
Clinical Assistant Professor of Psychiatry, NEOMED
Presented at Children’s Hospital Medical Center of Akron
September 27, 2018
59. What we’ll look at today…
• Examine the relevant literature evaluating the safety and
efficacy of antidepressants in children and teens.
• Provide an update on the risks of suicidal thoughts and
behavior in youth prescribed antidepressants
• Review the relative benefits and limitations of available
medications used to treat depression in kids
• Discuss other biological treatments for MDD in children and
teens
60. Question 1: Which of the following medications
are approved by the FDA for use in pediatric
depression?
• A: Paroxetine (Paxil)
• B: Venlafaxine XR (Effexor XR)
• C: Fluvoxamine (Luvox)
• D: Citalopram (Celexa)
• E. Escitalopram (Lexapro)
61. Question 2: Which of the following
statements about the TADS study is
true?
• A: CBT appeared to provide significant benefit to
depressed teens after twelve weeks compared to
placebo
• B: Teens treated with fluoxetine demonstrated an
increase in suicidal thoughts during the acute phase
of treatment
• C: Fluoxetine as a stand-alone treatment for
depression was more effective than CBT in acute
treatment
• D: There was no significant benefit from combining
CBT with fluoxetine in acute treatment
62. Question 3: Which of the
following statements is false:
• A: Most randomized studies of SSRIs in youth with depression
have demonstrated medication more effective than placebo
• B: SSRIs tend to demonstrate far more robust effect size for
treatment of anxiety in children and adolescents than for
depression
• C: The occurrence of increased suicidal thoughts in response to
treatment with SSRIs is greater in youth with depression than
anxiety
• D: Differences in delivery of cognitive-behavioral therapy in the
community may limit the ability to generalize results of treatment
in large scale studies of youth with depression or anxiety
64. MDD Diagnostic Criteria: DSM-5
• At least 2 weeks of pervasive change in mood manifest
by either depressed or irritable mood and/or loss of
interest and pleasure.
• Other symptoms: changes in appetite, weight, sleep,
activity, concentration or indecisiveness, energy, self-
esteem (worthless, excessive guilt), motivation, recurrent
suicidal ideation or acts.
• Symptoms produce clinically significant distress or
impairment
• Symptoms not attributable to substance abuse,
medications, other psychiatric illness, medical illness
American Psychiatric Association, 2013
65. Treatment options for
depression:
• Antidepressant medication
• Cognitive-Behavioral Therapy (CBT)
• Family Therapy
• Other therapies (interpersonal therapy, group therapy, supportive
psychotherapy)
(Evidence-based interventions in orange)
J Am Acad Child Adolesc Psychiatry, 2007; 46(11):1503-1526
66. Indications for Pharmacotherapy in
AACAP Practice Parameters for
Depression:
• Children, teens with moderate to severe
depression
• More severe episodes generally require
antidepressant treatment
• Medication may be administered alone until the
child is amenable to psychotherapy, or combined
with therapy from the beginning
• Youth who don’t respond to monotherapy
(medication or psychotherapy) require a
combination of medication and psychotherapy
J Am Acad Child Adolesc Psychiatry, 2007; 46(11):1503-1526
67. Metanalysis of Randomized
Trials of SSRIs:
• Effect size of SSRIs in MDD: 0.25
• Effect size in OCD: 0.48
• Effect size in non-OCD anxiety: 0.69
• Adolescents respond more robustly than school-age
children for both MDD and anxiety
• Better response to antidepressants in more severe illness
Bridge JA et al, JAMA 2007; 297(15):1683-1696
68. FDA approved medications for
MDD in children, adolescents…
• Fluoxetine for patients ages 8 and above
• Escitalopram for patients ages 12 and above
• Paroxetine not recommended for use in adolescent
patients
http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm413161.htm
69. Why does fluoxetine perform better
than other SSRIs in MDD?:
• Long half life makes inconsistent adherence less of
a concern
• Unique pharmacokinetic, pharmacodynamic
properties?
• Lower rates of discontinuation from withdrawal
symptoms
• Studies involved fewer sites, more experienced
investigators
Bridge JA et al, JAMA 2007; 297(15):1683-1696
70. The TADS (Treatment of
Adolescent Depression) Study
• NIMH sponsored “The Treatment of Adolescents with
Depression Study” (TADS):
• Multicenter controlled clinical trial
• 12-17 year olds with MDD
• Compared efficacy of fluoxetine, CBT, combination, &
placebo in 36 weeks with 1 year follow-up.
March J et al. J Am Acad Child Adolesc Psychiatry, 2006;45(12):1393-1403
75. Treatment Resistant Study
(TORDIA):
• NIMH funded multicenter study “Treatment of
Resistant Depression in Adolescents (TORDIA)
• Aims to benefit treatment-resistant adolescents, age
12-18 years old
• Compared fluoxetine, paroxetine, or venlafaxine,
either alone or in combination with CBT for 24 weeks
with 1 year follow-up
Brent D et al, JAMA, 2008;299(8):901-913
76. TORDIA Results:
• Response to CBT+2nd antidepressant 54%,
antidepressant alone 41% (significant)
• 2nd SSRI and Venlafaxine equally effective
• 2nd SSRI better tolerated than venlafaxine
Brent D et al, JAMA, 2008;299(8):901-913
78. Effect Sizes for SSRIs…
SSRI Use Effect Size
Anxiety 0.69
OCD 0.48
Depression 0.25
Bridge JA et al, JAMA 2007; 297(15):1683-1696
79. The FDA and Antidepressants
for Kids:
• Boxed warning regarding increased risk of suicidality
issued 10/15/04
• Antidepressants were not contraindicated in children
and adolescents
• Website for more info:
www.fda.gov/cder/drug/antidepressants/default.htm
81. How effective (or safe) is the
drug I might prescribe?
• Number Needed to Treat (NNT)
• The average number of patients who need to be treated
for one of them to benefit compared with controls in a
clinical trial
• Number Needed to Harm (NNH)
• The average number of patients who need to be exposed
to a specific risk factor so that one patient is harmed who
wouldn’t have been harmed absent the risk factor
• Benefit Risk Ratio
• Number Needed to Harm/Number Needed to Treat
82. Calculating the NNT…
Total number of patients treated
Responders to active treatment – Placebo responders
The “perfect” drug would have an effect size of 1.0
Exercise: 100 high school students are enrolled in a
double-blind study in which they receive one week of
Vyvanse and one week of placebo pills. 75 respond to
Vyvanse, 25 to placebo. What’s the NNT?
83. Metanalysis of Randomized
Trials of SSRIs:
• Increased risk of SI/SA in MDD vs. PBO: 0.9%
• Increased risk of SI/SA in OCD vs. PBO: 0.7%
• Increased risk of SI/SA in anxiety vs. PBO: 0.5%
Bridge JA et al, JAMA 2007; 297(15):1683-1696
84. Do risks and benefits vary by the condition
being treated?
(Number Needed to Harm)
0
50
100
150
200
250
Depression Anxiety OCD
Risks and benefits of antidepressant therapy
Harm=New onset suicidal thinking, behavior
NNH
85. Risk/Benefit Ratio of SSRIs by
condition treated
0
5
10
15
20
25
30
35
40
Depression Anxiety OCD
Risks and benefits of antidepressant therapy
Harm=New onset suicidal thinking, behavior
NNT Risk/Benefit
86. Predictors of Suicidal Events
Grcevich SJ et al. Presented at American Academy of Child and Adolescent Psychiatry, October 2009
87. SSRI side effects:
• Nausea
• Weight gain
• Behavioral activation/disinhibition
• Restlessness
• Vivid dreams
• Increased clotting time
• Fatigue
• Sexual side effects
98. ECT for Depression:
• No RCTs in adolescents
• May be effective treatment for adolescents with severe mood
disorders when more conservative treatments have been
unsuccessful.
• May be considered when there is a lack of response to two or more
trials of pharmacotherapy, when severity of symptoms precludes
waiting for a response to pharmacological treatment.
• Mood disorders in adults have a high rate of response to ECT (75%–
100%)
• Consent of legal guardian is mandatory, patient’s consent or assent
should be obtained.
• Systematic pre-treatment, post-treatment evaluation, including
symptom and cognitive assessment is recommended.
J. Am. Acad. Child Adolesc. Psychiatry, 2004;43(12):1521–1539.
99. Retrospective study of ECT:
• N=41 (mean age 17.0±1.8 years old)
• Mean duration of illness of 38.1 ± :26.9 months, 17.1% had prior ECT
• Psychotic symptoms (53.7%), depressed mood (43.9%), catatonia (17.1%),
suicidal behavior (17.1%), non-suicidal self-injury (7.3%), mania (2.4%)
• Mean of 9.6 ± 5.1 bi-frontal ECT treatments.
• Response rate: 70.0% in primary psychotic illness, 79.0% in youth with a
mood disorder.
• Higher response rate in depression vs. bipolar (92% vs. 44%, p=0.046).
• AE: Postictal agitation (12.5%), tachycardia (10%), headache, nausea (5%
each).
• “ECT was safe and efficacious, particularly in youth with unipolar
depression.”
Grudnikoff E. et al. 60th Annual Meeting of the American Academy of Child and
Adolescent Psychiatry, Orlando FL, October 2013
100. Conclusions:
• Pharmacotherapy is appropriate treatment option for
children, teens with moderate-severe MDD or kids with
MDD + suicidal ideation/plan
• Escitalopram has demonstrated efficacy in teens with
treatment-resistant MDD, but tolerated more poorly than
SSRIs
• Both SSRIs and CBT are associated with overall
decrease in suicidal ideation in teens with MDD
• While most kids with MDD improve in response to
treatment, full remission remains elusive, even with
medication + CBT
101. Psychosocial Treatment of Depression in Children
and Adolescents
Stephen Grcevich, MD
Clinical Assistant Professor of Psychiatry, NEOMED
Presented at Children’s Hospital Medical Center of Akron
September 27, 2018
102. What we’ll look at today…
• Examine the evidence base for psychosocial treatments of
depression in children and teens
• Discuss the limitations of the research literature on
psychotherapy for children and teens with depression
• Review the current knowledge regarding predictors and
modifiers of response to psychotherapy for teens with
depression.
103. CBT in children (under age 13)
with depression
• Seven controlled studies (patients compared to
waitlist or psychologically inert control)
• One study – positive findings in favor of CBT
• Four studies – generally positive, but more
equivocal findings
• Two negative studies
• “Possibly efficacious”
104. CBT modalities in children with
depression
• Three studies of individual CBT – “experimental
treatment”
• Four studies of group CBT – one of the four was
positive – “possibly efficacious”
• One positive study of CBT through
videoconferencing – “possibly efficacious”
105. Other psychosocial interventions
in children with depression
• One RCT compared individual psychodynamic
psychotherapy vs. family therapy
• Lots of missing data, difficult to ascertain effects
of natural remission
• Psychodynamic therapy marginally more
effective than family therapy
• Both individual psychodynamic and family
therapy considered “experimental” treatments for
children with depression
106. CBT in adolescents with
depression
• 27 randomized trials with control comparison
• CBT superior to control in 15/27 studies
• Findings replicated by independent investigators
• Considered a “well-established” treatment
107. CBT modalities in adolescents
with depression
• Fourteen studies of individual CBT – seven of
fourteen positive, including equivalence to
another effective treatment (IPT) - “well-
established treatment”
• Seven of twelve studies of group CBT positive –
“well-established treatment”
• One study of technology-assisted CBT failed to
demonstrate benefit compared to usual
treatment – “experimental”
• One of two trials of CBT bibliotherapy - positive
108. Interpersonal Therapy (IPT) in
adolescents with depression
• Six studies of IPT – five of six positive,
• Three of four studies of individual IPT positive
including equivalence to another effective
treatment (IPT) - “well-established treatment”
• Two positive studies of group IPT positive –
response in the third study was equal to “well-
established” treatments
• Group IPT – “probably efficacious”
109. Family Therapy in adolescents
with depression
• Five studies of family therapy – two positive, two
failed to separate from controls, inferior to CBT
in one study
• Difficult to interpret findings across studies
because of differences in modality used
• Family therapy – “possibly efficacious”
110. Predictors and moderators of psychotherapy
response in adolescents with depression
• Predictors – baseline characteristics of children,
teens and families associated with poor
response regardless of study conditions
• Moderators – baseline variables associated with
differential response to treatment modalities
111. Predictors of response to psychotherapy in
adolescents with depression
• Younger age of onset
• Shorter duration of
symptoms
• Better treatment
expectancy
• Readiness to change
• Poor global functioning
• Melancholic features
• Suicidality
• Non-suicidal self-harm
• Anxiety
• Cognitive distortions
• Hopelessness
• Family conflict
Positive Response Negative Response
112. Moderators of response to
psychotherapy in adolescents with
depression
• Higher severity of
symptoms
• Higher family income
(CBT)
• Comorbid anxiety
• Poor social functioning
(IPT)
• Increased family conflict
(IPT)
• Non-suicidal self-harm
• Comorbid substance
abuse
• Hopelessness
• Parental depression
Greater Response Lesser Response
113. Predictors of Outcomes in
TADS
• Younger age
• Less chronically depressed
• Higher functioning
• Less hopelessness
• Less suicidal
• Less melancholic
• Fewer comorbid diagnoses
• Greater expectations of improvement from treatment
Curry J et al. J Am Acad Child Adolesc Psychiatry, 2006;45(12):1427-1439
114. Modifiers of Outcomes in
TADS
• Combined treatment more effective than
medication in kids with moderate, but not severe
depression, kids with high levels of cognitive
distortions.
• CBT was equal to combined treatment in kids
from high income families
Curry J et al. J Am Acad Child Adolesc Psychiatry, 2006;45(12):1427-1439
115. Conclusions
• CBT and IPT are both effective and well-
established treatments in adolescents with
depression
• A paucity of research exists demonstrating
effectiveness of psychotherapy in children with
depression
• Overall trend in more recent research – more
modest benefits from treatment
• How much “evidence-based” psychotherapy is
available in the surrounding community?
116. Stay in Touch!
Family Center by the Falls: http://www.fcbtf.com
Phone: (440) 543-3400
E-mail: drgrcevich@fcbtf.com
https://www.facebook.com/StephenGrcevichMD
@drgrcevich