DEPRESSION IN DOWN
CHILDREN: CLINICAL
AND THERAPEUTICAL
REPORT ON 45 CASES.
Renato COCCHI, a
neurologist and a medical psychologist
Summary
A group of 45 depressed Down Ss
(17 M + 28 F; average ages: M = 15 years; F = 12 years) already underwent a
survey as for epidemiology (Cocchi R.: Riv. Ital. Disturbo Intellet. 1994, 7:
93-100). This second study aims to look at the therapy and its results.
The presence of depressed mood,
low self-esteem, irritability, reduced play or social interest, reduced use of
language etc, prompted the parents to ask for help.
These symptoms came out in
subjects undergoing drug therapy with l-glutamine, S-adenosil-l-methionine,
5-hydroxytriptophan and carbamazepine, which all possess some antidepressant
properties.
In this sample the female
prevalence inverted the usual M/F ratio with male prevalence among Down Ss, and
the age of the onset in female showed significant anticipation (.016).
Thirty-eight Ss had viloxazine as
the first used drug, three had amitriptyline, and four respectively had
fluoxetine, amitriptyline + perphenazine, clomipramine, imipramine. Six cases,
five on viloxazine and one on fluoxetine had their drug substituted by another
antidepressant (nortriptyline, amitriptyline, amitriptyline + perphenazine,
clomipramine, fluoxetine). At 30-60 days checkups of depressive symptoms showed
71.69% decrease (.0009).
Key words: Down’s syndrome;
depression: symptoms; drug therapy.
Down's syndrome
Drug modulations of stress reactions
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A group of 45 Down Ss out of a series of
510 having got specific antidepressant drugs treatment, underwent already a
study as for epidemiology (Cocchi, 1994).
This second investigation within the same
sample aims to look at the therapeutical point of view.
Materials
and method
The clinical records of 45 depressed Down
subjects (17 M + 28 F) treated by specific antidepressant drug therapies, and
already surveyed as for epidemiology (Cocchi, 1994) had a deeper examination.
From them I collected data such as:
- sex,
- chromosomal diagnoses,
- age of the onset of a clear depression,
- leading symptoms,
- antidepressant drugs used and their
daily doses,
- results.
Statistics: t test for two independent
samples and Chi Square.
Results
Tables 1-5 display the results.
Table 1: chromosomal anomalies
distribution
|
Chromosomal anomaly |
Nr. of Ss |
% |
|
Standard trisomy 21 |
38 |
84.44 |
|
Translocations |
1 |
2.22 |
|
Mosaicisms |
3 |
6.67 |
|
Unknown |
3 |
6.67 |
|
Totals |
45 |
100.00 |
The distribution of chromosomal
anomalies does not match both Italian and International distribution for large
series of Down subjects. So we cannot view this sample as representative.
Table 2: Depressive symptoms not
controlled by ongoing therapies
|
Symptom |
Nr. of Ss |
% |
|
|
||
|
Sadness |
28 |
62.22 |
|
Poor interest in play and social activities |
21 |
46.67 |
|
Irritability |
16 |
35.56 |
|
Low self-esteem |
15 |
33.33 |
|
Reduced speaking |
14 |
31.11 |
|
Aggressiveness |
9 |
20.00 |
|
Crying after frustration |
7 |
15.56 |
|
Craying without any cause |
6 |
13.33 |
|
Bed wetting |
5 |
11.11 |
|
To be spitful |
4 |
8.89 |
|
Jealousy of her/his siblings |
3 |
6.66 |
|
Hair or eyelash pulling |
2 |
4.44 |
|
Reactive depression to own father's dead |
1 |
2.22 |
Part of symptoms is the same one can
observe in adults' depressions, but part is more easily seen in childhood
depression.
Table 3: Ages (in months, by gender)
when the antidepressant
therapy was prescribed
|
Age parameters |
Males |
Females |
|
Average +/- SD |
187.65 +/- 89.11 |
140.48 +/- 35.44 |
|
Range |
103 - 474 |
65 - 231 |
t = 2.507 with 43 df and p = .016
C.I. 95% from 9.23 to 85.11
Surely a case with about 40 years could make
this late average onset of the illness in males debatable. Nevertheless, there
is a strong trend in this direction.
Table 4: antidepressant drugs used
|
Drug (mg/die) |
1st choice |
|
2nd choice |
|
|
|
Ss nr. |
% |
Ss nr. |
% |
|
|
||||
|
Viloxazine 25-100 |
38(*) |
84.44 |
|
|
|
Amitrptyline 10 + perphenazine 2 |
1 |
2.22 |
1 |
2.22 |
|
Amitriptyline 2-10 |
3 |
6.67 |
1 |
2.22 |
|
Fluoxetine 20 |
1 (*) |
2.22 |
1 |
2.22 |
|
Clomipramine 10 |
1 |
2.22 |
1 |
2.22 |
|
Imipramine 10 |
1 |
2.22 |
|
|
|
Nortriptyline 10 |
|
|
1 |
2.22 |
|
|
||||
|
Totals |
45 |
100.00 |
6 |
13.32 |
(*) 5 + 1 Ss had their
antidepressant drug changed
The choice of drugs used, and daily doses
accord with specificity and safety.
Table 5: results on checked symptoms
after 30-60 days therapy
(Key: 0 = not present; 1 = mild; 2 =
moderate; 3 = severe)
|
Symptom scores |
Ss. nr. |
before |
after |
% decreasing |
|
|
||||
|
Sadness |
28 |
70 |
9 |
87.14 |
|
Poor interest in play & soc. act. |
21 |
57 |
12 |
78.05 |
|
Irritability |
16 |
44 |
21 |
52.27 |
|
Low self-esteem |
15 |
34 |
7 |
79.42 |
|
Reduced speking |
14 |
28 |
2 |
92.56 |
|
Aggressiveness |
9 |
23 |
13 |
43.58 |
|
Crying after frustration |
7 |
20 |
8 |
60.00 |
|
Crayng without any cause |
6 |
17 |
3 |
82.35 |
|
To be spitful |
4 |
10 |
5 |
50.00 |
|
Jealousy of her/his siblings |
3 |
8 |
3 |
(62.50) |
|
Hair or eyelash pulling |
2 |
6 |
4 |
(33.33) |
|
React. depress. to father's death |
1 |
3 |
0 |
(100.00) |
|
|
|
|
|
|
|
Totals |
|
332 |
94 |
71.69 |
Chi Square = 38.413 with 12 df and
p < .0009
It is worthy to note the differences by which the symptoms respond to the therapy.
Discussion
This research has the same limits shown by
the preceding one on the same casuistry, dealing with epidemiological and
clinical aspects (Cocchi, 1994). I conducted it on Down subjects already
treated by drugs, according to given guidelines (Cocchi, 1993).
Several drugs they were taking (l-glutamine,
carbamazepine, S-adenosil-l-methionine, 5-hydroxytriptophan) possess
antidepressant properties, but were unable to avoid the onset of a frank
depression.
The present sample is shorter than what I
could have if sleep troubles, feeding troubles, constipation etc. were not
relieved or very mitigated by ongoing therapies.
Save some cases when I used a
tricyclic antidepressant to control bed wetting, I found prevalently
psychological symptoms. This fact somehow makes this form of depression similar
to many adults' depression.
Nevertheless, 8.82 % of frank depressions
out of the whole series of 510 Downs seems a noticeable rate. In this sample of
depressed Downs there is clear female prevalence as it usually happens in
normal people's depressions. This is a worthy interesting datum when we
remember that the sample comes out from a series of cases maintaining the usual
male prevalence, about 150/100.
Although one could debate such a
significant finding, the anticipation of depressive symptoms' onset in females
is undoubtedly a strong trend. If confirmed, it could be another feature
linking these ones to normal adults' depressions.
As for the origin of this depression, we
cannot ignore a reaction to the awareness of the social impact of the syndrome
as a major factor.
However, I should not undervalue the
biological features of the illness itself by its metabolic homeostatic
imbalance (Cocchi, 1993) as a strong concomitant cause.
About symptoms checked, sadness,
irritability, low self-esteem, aggression or self-aggression were already
reported by Fleisher & Weiler, 1992, as peculiar of children with a major
affective disorder (DSM-III, R: 276.22-3).
Other authors (Matson, 1982, 1983; McGee
and Menolascino, 1990) considered the remaining as depressive symptoms. Szymanski
and Biederman in 1984 and Warren, Holroyd and Folstein (1989) noted depression
in Down children. As I know now, this is the first clinical and therapeutical
casuistry related to home reared Down subjects.
Moreover it is interesting to note it,
because of its large size and being derived from the clinical experience of
only one consultant.
In the drug choice, I mostly preferred
viloxazine following two features, its noradrenergic action and its not to
lower the epileptic threshold (Cocchi and Occhialini, 1981, 1982). Having Down
Ss reduced brain noradrenergic neuro-transmission, the use of a noradrenergic
drug by that has its justification.
Only six cases out of 45 needed to switch
on a more powerful antidepressant drug, a tricyclic antidepressant in 5 of
them. Viloxazine worked well in 38 cases, and this proved its efficiency. As
usual, I prescribed low daily doses because I maintain a synergistical effect
of the polytherapy.
The 71.69% whole reduction of depressive
symptoms falls in the efficiency range of antidepressant drugs. It could be
curious noting that symptoms less reduced, like irritability, aggressiveness,
crying after frustration, to be spiteful and hair pulling are those that allow
peripheral adrenergic compensation.
One can suspect that, having the child
some awareness of their homeostatic function, he does not leave them, even when
depression - which originated them - largely narrows down.
Conclusion
Today there are no doubts about frank
depressive episodes in mentally retarded people, even Down people. Child
psychiatrists begin to not have any difficulty in recognizing a dual diagnosis
and in treating the superimposed new disease.
As for my experience, frank depression in
Downs is quite similar to what happens in "normal" non Down persons, and
we can face it with more than good perspectives of success. This report seems
to be now one of the major casuistry on this topic. However I do not pretend to
have presented a paradigmatic example, but only to give some lines of approach
to drug therapy of this mental emergency in Downs subjects.
References
Cocchi R.: Drug therapy in Down syndrome.
A theoretical context. It. J. Intellect. Impair. 1993, 6: 143-154.
Cocchi R.: La depressione nel soggetto
Down: Indagine epidemiologica e clinica su 510 casi. Riv. Ital. Disturbo.
Intellet. 1994, 7: 93-100.
Cocchi R., Occhialini O.: La viloxazina
come farmaco di scelta nella depressione degli epilettici e dei cerebropatici:
13 osservazioni. Rass. Studi Psichiat. 1981, 70, 1-9 (numerazione estratto).
Cocchi R., Occhialini O.: La viloxazina
nei bambini cerebropatici con o senza epilessia. Rapporto su 8 casi. In:
Antidepressivi atipici. Alternative ai triciclici nella terapia della
depressione. Flaccovio, Palermo 1982: 203-206.
Fleisher M.H., Weiler M.A.: The prevalence
and specific aspects of depression in retarded individuals. In: Dosen A.,
Menolascino F.J.: Depression in mentally retarded children and adults. Logon,
Leiden, 1990: 51-61.
Matson J.L.: Depression in the mentally
retarded: A review. Educ. Train. Ment.Retard. 1982, 17: 159-163.
Matson J.L.: Depression in the mentally
retarded: Toward a conceptual analysis of diagnosis. In: Hersen M., Eisler R.,
Miller P. (eds): Progress in behavioral modification. Academic Press, New York,
1983.
McGee J.J., Menolascino F.J.: Depression
in persons with mental retardation: towards an existential analysis. In: Dosen
A., Menolascino F.J.: Depression in mentally retarded children and adults.
Logon, Leiden, 1990: 95-111.
Szymanski L.S., Biederman J.: Depression and
anorexia nervosa of persons with Down syndrome. Am. J. Ment. Defic. 1984, 89:
246-251.
Warren A.C., Holroyd S., Folstein F.:
Maior depression in Down syndrome. Br. J. Psychiat. 1989, 155: 202-205.
Printed on It. J. Intellect. Impair. 1995, 8: 191-196.
Author's address: dr Renato
COCCHI, via Rabbeno, 3
42100 Reggio Emilia (Italy)
renatococchi@libero.it
Down's syndrome
Drug modulations of stress reactions
Testo in italiano
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