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Characterizing Depression and Coexisting Sleep
Disorders in Adolescents & Adults with DownSyndrome
George T Capone, MDDirector, Down Syndrome Center
Kennedy Krieger Institute
Baltimore, Marylandwww.kennedykrieger.org
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DownSyndrome&MentalHealth
AAP Health Supervision Guidelines for Children (2011)Healthcare Guidelines for Adults?Depression, anxiety, other MH concerns
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MentalHealthConcernsinAdolescents
&Adults
A9meforconcernedparen9ng
LifeEvents:psychosocialstressors,rela9onships,transi9ons Social:self-awareness,keepingupatwork-school,thebigpond
Lifestyle:socialrela9onships,exercise,ac9vitylevel Puberty:hormones&re-organiza9onofbrainconnec9ons Medicalcondi9ons:appe9te-weight,sleep,generalhealth
Trisomy21:con9nuingimpactonbrainfunc9onthroughoutlife?
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ChallengesManagingMentalHealth
Disorders
DiscomfortwithMentalHealthIssuesinDS/ID LimitedresourcesforMentalHealthandID
Diagnos9covershadowing(DSorAD) Diagnos9cuncertainty-complexsymptompresenta9on Therapeu9cuncertainty-
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Depression&DownSyndrome
Mood,anxiety,compulsivedisordersincreasepost-puberty(10-15%)
Grief,bereavementoradjustmentreac9on?IsNOTMajorDepression
DepressionmayseemtoappearunexpectedlyIsageassociatedwithriskofMajorDepression?
Mostcommonbetween15-25yr Male=Female DoesNOTappeartoshowalinearincreasewithage Demen9aprodromevsotherrisk-factors?
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MajorDepressiveEpisode&DownSyndrome
Warrenetal.(18)reportedonyoungadults
Dis9nguishedmajordepressionfromAD-typedemen9a
Symptom-complexincluding:
Apathy,socialwithdrawal Func9onaldeclineincogni9ve-adap9veskills Psychomotorslowing Deteriora9onfromanestablishedbaseline
Confirmatoryreports:
Cooper&Collaco`(10s),Myers&Pueschel(15),Prasher(16) Khanetal(2002),Walkeretal(2011)forreviews
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Case-ControlStudy:DS+MajorDepression
RecruitedthroughDSClinicatKKI
Diagnos(cGroups DSSubjects Func(onal
decline
MajorDepressiveEpisodeMDE) N=1 13(68%)MDE+Psychosis N= 6(66%)Ageatevalua(onyears) 21.0+5Symptomdura(onmonths) 12.8+.1
MentallyHealthyDSControls) N= 0Ageatevalua(onyears) 1.8+7.1
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ThyroidFunc9on
MDE Controls
Thyroid Status N=28 N=9
Thyroid supplement 11/28 (39%) 4/9 (44%)
Euthyroid (TSH 0.5-5.5 uIU/ml) 27 (96%) 9 (100%)
Compensated (TSH > 5.5uIU/ml;normal T4)
1 0
Hypothyroid (low T4) 0 0
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ReissScalesofChildrensDualDiagnosis
0
1
2
3
4
5
6
Anger
Anxiety
A`en9on
Au9sm
Conduct
DepressionSelf-Esteem
Psychosis
Somatoform
Withdrawn
OtherBehavior
"Spider-Graph"CompositeMDEvsControlsMDE Controls
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IsThereanAssocia9onbetween
DepressionandSleepApnea?
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NeuroanatomyofSleepApneainAdults
Brain MRI
Red = significantlyincreased gray
matter loss
Macey, et al 2002
Lal, et al 2012
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SleepApnea:Severity&TonsillectomyStatus
MentalHealth
Diagnosis%with
Sleep
Apnea
Mod-
Severe
Apnea
N=16
Mild
Apnea
N=12
No
Apnea
N=9
Previous
tonsil
removal
N=15
Majordepressive
episodeMDE)N=28 86% 1554%) (32%) 4(14%) 12(43%)
NomentalhealthdiagnosisN=9 44% 1(11%) 3(33%) 555%) 3(33%)
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RespiratoryEvents&Oxygena9onData
MDE Controls RespiratoryEvents N=28 N= t-test
Apnea/HypopneaIndexn/hr) 18.814.7 4.53.8 .001REM-Apnea/HypopneaIndexn/hr) 35.835. 11.10.2 .01RespiratoryDisturbanceIndexn/hr) 24.324.6 7.37.3
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SleepArousalData
MDE Controls Arousals N=28 N= t-test
TotalArousalIndex 22.420.1 16.415.7 NSRespiratoryArousalIndex 14.917.9 2.73.1
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SleepStageData MDE Controls
SleepArchitecture N=28 N= t-testSleepEfficiency%) 70.520.3 77.316.2 NSN1TST%) 6.07.2 6.55. NSN2TST%) 58.520.3 58.12.5 NSN3TST%) 25.016.7 21.25.0 NSREMTST%) 8.37.5 12.16.4 .15tREMlatencymin) 187.5106.2 227.165.0 NS
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Limita9onsofthisStudy
SyndromeofCo-exis9ngDepression+OSA(notcharacterized)
Delayinpresenta9on-diagnosis(symptomseverity-reversibility)
Dura9onofsleep-respiratorysymptoms(chronicstress)
Medica9oneffectsonsleeppa`ern Otherpsychosocialstressors(triggers?) Demen9aprodrome(amyloid,monoamines)? Case-controldesigndoesnotaddresscausality Carefullymatchedcontrols
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FurtherResearchonSleepApnea&Depression
CausalityorCo-Morbidity?
Researchsleepstudies:mul9plenights,medica9onnavesubjects
Characterizeandmeasure:
Psychiatricsymptomsandcogni9vefunc9on Social-adap9veskills,func9onaldecline Lifeevents,impactoncaretakers
Biomarkers:fordepression&OSA
Biologicalpsychologicalvulnerability(individualriskfactors)Clinicalinterven9onstudies:
Standardofcaretreatments:medica9ons,weightloss,CPAPorENTairwaymanagement
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ThankYou