Coping with Mood Disorders in Adolescents: Strategies for Family Caregivers David J. Miklowitz, Ph.D. Professor of Psychiatry Division of Child and Adolescent Psychiatry, UCLA Semel Institute and Department of Psychiatry, Oxford University UCLA Child and Adolescent Mood Disorders Clinic www.semel.ucla.edu/champ (310) 825-2836
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Coping with Mood Disorders in Adolescents: Strategies for ......The Bipolar Disorder Survival Guide: What You and Your Family Need to Know. Second Edition. New York, NY: The Guilford
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About 9% of adolescents have had a major depressive
episode
More common in girls than boys after puberty; equally
common before puberty
Suicide is third leading cause of death in US in ages 15-24
Often goes unrecognized; attributed to “teen angst” or
“raging hormones”
Up to 33% of teens convert to bipolar disorder later on
Associated with many comorbidities (e.g., anxiety)
Only about 50% improve with antidepressants
Pediatric-Onset Bipolar Disorder
2.5% of adolescents age 13 -181,2
At risk for the 4 S’s3:
School problems
Substance abuse
Suicide
Social dysfunction
High comorbidity rates
Long delays until treated3,5
Stronger genetic load than in adults4
Poorer prognosis, less time well5
1 Van Meter et al, 2011, J Clin Psychiatry; Merikangas et al., 2012, Arch Gen Psychiatry; 3Goldberg et al., J Nerv Ment Dis., 2004; 4Faraone et al., Biological Psychiatry, 2003; 5Leverich GS et al. (2007), J Pediatr 150(5):485-490
When there has been: a significant change in moods: sadness, loss of interests,
sleep changes, fatigue
Any suicidal talk or preoccupation with death
Deterioration in functioning (school, friends, responsibilities)
Impulsive, dangerous or risk-taking behavior
A psychiatric eval does not automatically mean
s/he will have to take medications
Physician may uncover a biological dysregulation
(e.g., low thyroid)
Troubleshooting Medication
Adherence in TeensAbout 35% are nonadherent in year after an episode
Discuss side effects with doctor
Develop strategies for pill storage and use
Role of medications in family:
Does kid feel she’s taking meds for herself or others?
Pressures from family members to discontinue
medications?
What is the symbolic significance of taking medications
(loss of creativity? Giving up emotions)?
“Grieving over the lost healthy self”
1Miklowitz DJ & Goldstein MJ. Bipolar Disorder: A Family-Focused Treatment Approach. NY: Guilford Press, 1997.2Frank E, et al. Biol Psychiatry 48(6):593-604, 2000.
Principle #5
Develop a prevention plan for future
mood episodes
The Prevention Action Plan
List prodromal signs of past episodes
List stressors or other circumstances in which,
historically, these have occurred
Coping strategies: What can you do?
What can your spouse or other family members do?
The psychiatrist? Therapist?
What are the obstacles?
Have all emergency contact info in one place
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Handout #11
Stressors or Triggers Early
Warning
Signs
Coping Skills Overcoming
Obstacles
1
2
3
4
5
6
7
8
9
10
Prevention Action Plan
Handout #11
Stressors during last episode
Early
Warning
Signs
Coping Skills Overcoming
Obstacles
1 Arguments with dad, brother
Sleeps less, gets up during night
Contact Dr. Stevens for medication check
Find best phone number for doc, therapist
2 Fired from after-school job
Irritable, picks fights
Try to keep regular bedtime
Computer games may involve other people
3 Obsessed with video games
Agree on hours for computer usage
4 Talks loudly about ways to make money
Stay away from friends who make me want to smoke weed
5
6
7
8
Prevention Action Plan for Manic Episodes: Phil
Things to do to when adolescent may
be getting manic
Contact physician for medication change
Avoid driving
leave credit cards at home
when going out at night, bring along
someone you/they trust
For life decisions: use the 2-person rule
and the 48 hr rule
Things to do when adolescent is
getting more depressed
Focus on structure – getting up at a reasonable
time, have predictable places to go
Increase family support: encourage regular family
meals, stay away from “hot topics”
Increase frequency of positive events (e.g.,
contacts with friends, outdoor activities)
Meditation or yoga; exercise
Offer to talk to him/her (but it may not be
welcome)
Avoid taking on “therapist role”
Principle #6
Work on communication and problem-
solving
12 – 21 outpatient sessions over 4-9 months
Assessment of patient and family
Engagement phase
Psychoeducation about bipolar disorder (symptoms,
early recognition, etiology, treatment, self-
management)
Communication enhancement training (behavioral
rehearsal of effective speaking and listening
strategies)
Problem-solving skills training
Family-Focused Treatment (FFT)
of Bipolar Disorder
Miklowitz DJ. The Bipolar Disorder Survival Guide: What You and Your Family Need to Know. Second Edition. New
York, NY: The Guilford Press; 2010.
How Can The Family Help?
•Help child get treatment and support services (e.g., IEP)
• Support use of medication
• Maintain tolerant and calm home atmosphere
(What behavior is controllable by teen and what isn’t)?
•Have fair expectations for performance after an episode
•Make sure the needs of healthy siblings are recognized