How to treat adolescents with mood disorders from depression to mania?

Now that new DSM 5 introduced new “mixed features” specifier for major depressive disorder, first time identifying manic symptoms within depressive disorders spectrum, the view of the gap between mania and depression dichotomy needs to be replaced with mood disorders spectrum. Thus, early identification of bipolar disorder (BP) youth, especially during depression, and early identification of manic symptoms in major depression (MDD) is critical not only to improve the long-term prognosis of adolescents with mood disorders, but also to prevent inappropriate treatments. As demonstrated recently in adults, improving the accuracy of early diagnosis of BP in youth may be achieved by identifying objective neural biomarkers at an early age that are specific to BP and not common to MDD, which in turn can help identify predictors of treatment response. Treatment guidelines for BP in children and adolescents were recently developed, but the panel left out depression and agreed that there was insufficient evidence to develop a treatment algorithm for it. Several studies suggest that there were effective and well-tolerated treatment options (e.g., lithium, mood stabilizers, second-generation antipsychotics [SGA]) for manic or mixed episodes of BP in youth; however, there are no maintenance studies in depressed children and adolescents with BP and available data for depressive episode in BP is limited to few randomized and two open-label acute treatment studies in adolescents. Management of depression is very different in BP depression than in MDD: Antidepressants are widely used in MDD, but may exacerbate or induce mania and suicide in depressed BP youth. Antidepressant monotherapy is therefore contraindicated for the treatment of BP depression, and studies in depressed BP adults show that combining antidepressants with mood stabilizers may also not be effective. Furthermore, we know very little about treatment of MDD with mixed features, but those adolescents with episodic severe but short lasting manic episodes are at very high risk for developing BP over the next4-5 years. Treatment of mood disorder in adolescents should be tailored for each individual b taking into account their developmental history, family history, comorbidities, and mood disorder spectrum approach.