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Bipolar Disorder and Depression in Childhood and Adolescence

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Bipolar Disorder and Depression in Childhood and Adolescence 0021-7557/04/80-02-Supl/S11 Jornal de Pediatria Copyright © 2004 by Sociedade Brasileira de Pediatria ARTIGO DE REVISÃO Depressão e doença bipolar na infância e adolescência Bipolar disorder and depression in childhood and adolescence Dênio Lima* Resumo Abstract Objetivos: Este estudo buscou a revisão da história, conceitos, Objectives: To provide a historical review of childhood depression categorias diagnósticas, epidemiologia, fatores genéticos e neurobioló- and bipolar disorder, covering concepts, diagnostic categories, gicos, assim como fatores predisponentes e modalidades de tratamento epidemiology, genetic and neurobiological aspects as well as predisposing desses transtornos. factors and treatment modalities. Fontes dos dados: Foi realizada uma revisão extensa da literatura Sources of data: Extensive review of the literature on child sobre depressão infantil e transtorno bipolar. depression and bipolar disorder. Síntese dos dados: A depressão infantil e o transtorno bipolar Summary of the findings: Child depression and bipolar disorder estão associados a fatores genéticos, temperamento, eventos adversos are associated with genetic factors, mood, adverse life events, divorce, da vida, divórcio, problemas acadêmicos, abuso físico e sexual e fatores academic problems, physical and sexual abuse, and neurobiological neurobiológicos. O tratamento pode ser realizado, na maioria das factors. Treatment usually includes medication and psychotherapy. vezes, com medicações e psicoterapia. Conclusions: These are important childhood disorders whose Conclusões: São transtornos importantes, muitas vezes de difícil diagnosis is often difficult. The identification and treatment of depression diagnóstico, que, uma vez reconhecidos e tratados, irão minorar o and bipolar disorder reduces the suffering of affected children and sofrimento de crianças e adolescentes. O pediatra poderá intervir adolescents. The pediatrician can intervene by orienting the family in orientando a família nos casos leves, mas deve ficar atento àqueles que mild cases, but must be alert to cases requiring more aggressive necessitam de outros tipos de tratamento. treatment. J Pediatr (Rio J). 2004;80(2 Supl):S11-S20: Depressão infantil, J Pediatr (Rio J). 2004;80(2 Supl):S11-S20: Child depression, transtorno afetivo, mania, transtorno bipolar. mood disorder, mania, bipolar disorder. Introdução O conceito de depressão na criança ainda é bastante a depressão que aparece na infância e a depressão de controverso. Até pouco tempo pensava-se que a depres- adultos não é muito correta, e muitos autores continuam são infantil não existia ou que aparecia em uma forma a duvidar sobre a verdadeira freqüência de síndromes mascarada. depressivas em pré-puberes4-6. É preciso ressaltar que o Nos últimos 20 anos, começou-se a reconhecer que as conceito de transtorno depressivo em adultos tem muitos condições depressivas dos adultos também podiam apa- tópicos controvertidos. Embora recentemente grande recer em crianças1-3. No entanto, esta comparação entre progresso tenha sido feito no diagnóstico e classificação de transtornos afetivos em adultos, é óbvio que um grande número de problemas continua sem solução7. Na verdade, os problemas que aparecem no estudo de de- pressão em crianças, em muitos aspectos, são muito * Doutor, Professor adjunto, Universidade de Brasília. próximos daqueles que ocorrem nos estudos dos adultos. S11 S12 Jornal de Pediatria - Vol. 80, Nº2(supl), 2004 Depressão e doença bipolar Lima D O sentimento de tristeza faz parte da experiência normal existe uma ressalva para os transtornos do humor que se da pessoa. O conceito de depressão, no entanto, não é manifestam na infância ou adolescência), os transtornos sinônimo de tristeza ou infelicidade, apesar da infelicidade do humor (afetivos são classificados no grupos F.30-39) ser um componente comum do humor depressivo associado devem ser registrados pelo uso de categorias desta ao transtorno. A depressão pode se apresentar como um seção, desde que se ajustem às descrições fornecidas sintoma, quando o afeto é a tristeza, ou como uma síndrome (transtornos mistos de conduta e emoções ou F.92.0). ou transtorno, quando apresenta um grupo de sintomas que aparecem juntos, com a tristeza fazendo parte de um grande elenco de problemas, que pode incluir a perda de Episódio depressivo interesse nas atividades, sentimento de desvalia, perturba- Em episódios depressivos leves, moderados ou graves ções do sono, mudanças do apetite, entre outros. típicos, o paciente sofre de rebaixamento do humor, redu- O humor negativo da depressão pode ser representa- ção de energia e atividade diminuída. A capacidade de sentir do por aspectos como sentimento de um vazio emocional prazer, interesse e concentração estão diminuídos, e é ou sentimento emocional achatado, plano. Muitos pacien- comum o cansaço marcante após esforço, mesmo mínimo. tes descrevem o seu humor como sendo uma nuvem O sono é perturbado e o apetite é diminuído. A auto-estima negra pairando sobre suas cabeças. Existe uma variação e a confiança em si próprio quase sempre estão reduzidas, diária, e um dia pode ser pior que o outro. A anedonia e estão presentes com freqüência idéias de culpa e desva- (incapacidade de obter prazer nas atividades em que lorização, humor rebaixado, hábito de despertar várias antes se obtinha) também aparece relacionada à depres- horas mais cedo que o habitual, marcante retardo psicomo- são como sintoma. tor, agitação, perda do apetite, de peso e da libido. Recentemente houve uma enfatização da importância Para a criança e o adolescente, a CID-10 inclui a dos chamados aspectos cognitivos da depressão, e alguns categoria transtorno depressivo de conduta, que é a com- autores acreditam que este conceito é essencial. Alguns binação de transtorno de conduta na infância (F 91.-) com pacientes depressivos têm sentimento intenso de inade- persistente e marcante depressão do humor (F 32.-), quação pessoal e tendência para apresentar baixa auto- evidenciada por sintomas como sofrimento excessivo, per- estima (uma opinião depreciativa sobre si mesmo), acredi- da de interesse e prazer em atividades usuais, auto- tando que outras pessoas o vêem depreciativamente. recriminação e desesperança; perturbações do sono ou O afeto depressivo e a cognição depressiva são expe- apetite também podem estar presentes. Alguns requisitos: rimentados por várias pessoas no decorrer da vida, Os critérios gerais para transtornos de conduta (F 91) fazendo parte da vida normal, sem conotação patológica. devem ser satisfeitos. Ao contrário, o termo síndrome é mais do que um simples Os critérios gerais para transtorno de humor (afetivos sintoma isolado; ele agrega uma combinação de vários ou F 30-39) devem ser satisfeitos. sintomas que constituem um complexo, determinando a Ainda há relutância em se aceitar os casos de depres- síndrome depressiva. são identificados na comunidade e aqueles tratados por Nas classificações de doenças mentais, temos o Manu- psiquiatras. Essa relutância é devida à consideração do al Estatístico para Doenças Mentais (DSM-IV)8, que re- que é angústia ou doença. A chave desse aspecto tem sido quer, para a definição de depressão maior, os aspectos a diferenciação entre o que é depressão e o que é uma abaixo relacionados, independentemente da idade: reação normal devido ao estresse resultante de aconte- Cinco ou mais dos seguintes sintomas, durante duas cimentos da vida, tais como desmoralização. Infelizmen- semanas, sendo pelo menos um deles humor deprimido te, a evidência disso é inconclusiva ou freqüentemente ou perda do interesse ou prazer: humor deprimido contraditória. Nos adultos, está bem estabelecida a rela- quase todos os dias; acentuada diminuição do prazer; ção entre o início do episódio depressivo e o evento perda ou ganho de peso (mais de 5% em 1 mês); insônia adverso que o precede. ou hipersonia; agitação ou retardo psicomotor; fadiga ou perda de energia; sentimento de inutilidade ou culpa excessiva; diminuição da capacidade de pensar; pensa- Conceito e classificação mentos de morte recorrentes; ideação suicida sem plano específico ou tentativa. Os conceitos são comparados aos do adulto. No entan- Os sintomas não satisfazem os critérios para episódio to, existem problemas associados ao uso desses concei- misto. tos de adulto em crianças. Os sintomas causam sofrimento clinicamente significa- Dependendo da idade, as crianças podem apresentar tivo ou prejuízo do funcionamento social. diferentes sintomas. Isso porque, quando muito pequenas, elas não têm capacidade de se expressar. Podem ficar muito Os sintomas não se devem a efeito de substâncias ou chorosas ou apresentar irritabilidades e queixas somáticas. condição médica geral. Alguns autores acham que um dado que deveria ser bastan- Os sintomas não são mais bem explicados por luto. te valorizado é a recusa para ir a escola. Quando são Na Classificação de Transtornos Mentais e de Compor- maiores ou na adolescência, os sintomas já são mais tamento da CID-109, que é destinada a adultos (mas parecidos com os dos adultos. Depressão e doença bipolar Lima D Jornal de Pediatria - Vol. 80, Nº2(Supl), 2004 S13 Depressão anaclítica prévios e sem acentuada psicopatologia familiar; b) for- O primeiro estudo que ligou a depressão infantil à ma crônica depressão típica, freqüentemente com condição depressiva maior do adulto foi o de Spitz.10, que pobre ajustamento antes do início do transtorno e ten- 16 descreveu a síndrome de depressão anaclítica. De dência a vir de um meio desajustado . acordo
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