Update on Adolescent Mood Disorders

January 23, 2013

In line with adolescents' interest in interactive video games, a computerized cognitive-behavioral therapy intervention that is an interactive fantasy game for depressed adolescents has been developed.

Some recent studies provide clinically useful information about treatment and screening for adolescent depression and the course of adolescent bipolar disorder. In line with adolescents’ interest in interactive video games, Merry and colleagues1 developed a computerized cognitive-behavioral therapy intervention that is an interactive fantasy game for depressed adolescents. In this 3-dimensional CD-ROM game, SPARX (smart, positive, active, realistic, X-factor thoughts), the adolescent chooses an avatar and tries to restore balance in a fantasy world dominated by GNATS (gloomy, negative automatic thoughts).2

The game consists of 7 levels, each with a different province (eg, cave, volcano) containing different content. The contents include finding hope, being active, dealing with emotions, overcoming problems, recognizing unhelpful thoughts, challenging unhelpful thoughts, and bringing it all together. At the beginning and end of each of these levels, the adolescent interacts with a guide who explains the game, provides education, assesses mood, and sets and monitors real-life challenges.

The effectiveness of SPARX in the treatment of 187 adolescents with depressive symptoms was assessed in a randomized controlled trial that compared SPARX with treatment as usual (counseling) over 4 to 7 weeks. There were similar reductions in Children’s Depression Rating Scale–Revised (CDRS-R) scores between SPARX and treatment as usual at the end of the intervention. Response rates (defined as 30% decrease in CDRS-R scores) were similar for SPARX (66.2%) and treatment as usual (58.3%). The authors concluded that SPARX may be a useful intervention for adolescents with depression, especially since it is readily accessible.

In pediatric care settings, clinicians are often in need of screening instruments for the assessment of depression in adolescents. Allgaier and colleagues3 examined the validity of the Patient Health Questionnaire 9-Item (PHQ-9) and 2-Item (PHQ-2) in 322 adolescents from pediatric hospitals and clinics.4,5 The PHQ-9 items include interest or pleasure, mood, sleep, fatigue, appetite, self-esteem, concentration, psychomotor retardation or agitation, and suicidality, whereas the PHQ-2 items are interest or pleasure and mood.

The PHQ-9 and the PHQ-2 were compared with depressive diagnoses obtained by a structured diagnostic interview. The diagnostic accuracy was significantly higher for the PHQ-9 (area under the curve [AUC] = 93.2%) than for the PHQ-2 (AUC = 87.2%). Sensitivity was similar between these two versions, PHQ-9 (90%) and PHQ-2 (85%), but the specificity was higher for the PHQ-9 (86.5%) than for the PHQ-2 (79.4%). The authors concluded that both versions of the PHQ are valid screening tools; however, the PHQ-9 is a more valid instrument for adolescents with depression.

Adolescents may have symptoms of hypomania ranging from full syndrome to brief episodes (less than 4 days) and subsyndromal hypomania. It is important to know whether these hypomania spectrum disorders will continue in adulthood. Pren and colleagues6 conducted a 15-year longitudinal follow-up of 64 adolescents who had a lifetime hypomania spectrum episode. In adulthood, 2 (3%) had mania, 4 (6%) had hypomania, and 38 (59%) had depression.

These findings demonstrate that relatively few adolescents who had hypomania spectrum episodes continue to have hypomania in adulthood. No differences in adulthood mood symptoms were found between the different subgroups of hypomania. Adolescents who had a first- or second-degree family member with bipolar disorder were more likely to have bipolar disorder in adulthood. On the basis of these findings, these researchers question the long-term use of mood stabilizers in adolescents who have had a hypomanic episode.

Youths with bipolar disorder are at significant risk for suicide. Using a longitudinal 5-year study, Goldstein and colleagues7 examined risk factors for suicide attempts in 413 children and adolescents with a diagnosis of bipolar I disorder (n = 244), bipolar II disorder (n = 28), or bipolar disorder not otherwise specified (n = 141). Many (76; 18%) of the youths made a suicide attempt at least once during the follow-up period. Thirty-one (7%) attempted suicide multiple times. There were no significant differences in the rate of suicide attempts among youths with bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified.

The strongest predictors of suicide attempts were severity of the depressive episode at baseline and a family history of depression. Predictors of suicide attempt in the preceding 8-week period were mixed mood symptoms, substance disorder, and more weeks with depression. The authors recommended that these risk factors for suicide attempts be carefully assessed when treating youths with bipolar disorder.

Family functioning can affect and, in turn, is affected by, the symptoms of bipolar disorder in adolescents. Sullivan and colleagues8 examined the relationship between family functioning and symptoms of bipolar disorder in adolescents. Fifty-eight families of adolescents with bipolar disorder participated in a 2-year randomized trial of family-focused treatment for adolescents. The measures of family functioning included family cohesion, adaptability, and conflict. Family cohesion and adaptability did not change over the 2-year period. However, family conflict at baseline predicted the severity of adolescents’ manic symptoms over time. Adolescents’ symptoms of mania showed more rapid improvement in low-conflict than in high-conflict families. It was also found that a decrease in parent-reported conflict led to a decrease in adolescents’ symptoms of mania. The authors concluded that family conflict should be addressed in the treatment of adolescent bipolar disorder.



1. Merry SN, Stasiak K, Shepherd M, et al. The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomized controlled non-inferiority trial. April 19, 2012. http://www.bmj.com/content/344/bmj.e2598. Accessed December 11, 2012.

2. SPARX. http://www.sparx.org/nz. Accessed December 12, 2012.

3. Allgaier AK, Pietsch K, Frühe B, et al. Screening for depression in adolescents: validity of the patient health questionnaire in pediatric care. Depress Anxiety. 2012;29:906-913.

4. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613.

5. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: vailidity of a two-item depression screener. Med Care. 2003;41:1284-1292.

6. Päären A, von Knorring AL, Olsson G, et al. Hypomania spectrum disorders from adolescent to adulthood: a 15-year follow-up of a community sample. J Affect Disord. 2012 Aug 9; [Epub ahead of print].

7. Goldstein TR, Ha W, Axelson DA, et al. Predictors of prospectively examined suicide attempts among youth with bipolar disorder. Arch Gen Psychiatry. 2012 July 2; [Epub ahead of print].

8. Sullivan AE, Judd CM, Axelson DA, Miklowitz DJ. Family functioning and the course of adolescent bipolar disorder. Behav Ther. 2012;43:837-847.