Substance Induced Mood Disorder

Manic or depressive episodes may result from medications, alcohol or drugs of abuse, or toxic agents. DSM-IV-TR specifies that the mood disturbance, either manic or depressive, must have developed within 1 month of substance intoxication or withdrawal; that the substance (or medication) must be etiologically related to the disturbance; and that these clinical conclusions must be based on the medical history, physical examination, or laboratory findings (see Table 6-11). Alcohol, cannabis, opiates, cocaine, stimulants, sedatives, and anabolic steroids are commonly associated with depressive symptoms in adolescents with manic symptoms.

Table 6-8. General medical conditions that may present with mood symptoms

Autoimmune disorder

Neoplasms

Systemic lupus erythematosus

Central nervous system primary and metastatic tumors

Endocrine disorders

Endocrine tumors

Diabetes mellitus

Paraneoplastic syndromes

Gonadotropic hormonal disturbances

Neurological and cerebrovascular disorders

Hyperadrenalism

Brain neoplasms

Hyperparathyroidism

Epilepsy

Hyperthyroidism

Head trauma

Hypoadrenalism

Huntington's disease

Hypoglycemia

Idiopathic calcification of basal ganglia

Hypoparathyroidism

Metachromatic leukodystrophy

Hypothyroidism

Migraine

Panhypopituitarism

Multiple sclerosis

Pheochromocytoma

Narcolepsy

Infectious diseases

Normal-pressure hydrocephalus

AIDS

Postconcussion stroke

Bacteremia and viremia

Posttraumatic encephalopathy

Brain abscess

Stroke

Infectious mononucleosis

Nutritional deficiencies

Neurosyphilis

Folate deficiency

Pediatric autoimmune neuropsychiatric disorders

Malnutrition/dehydration

Streptococcal infections

Nicotinic acid

Tuberculosis

Thiamine deficiency

Viral hepatitis

Trace metal deficiency

Viral meningitides and encephalitides

Vitamin B12 deficiency

Metabolic and systemic disturbances

Toxins

Chronic hypoxemia

Environmental toxins (e.g., lead, carbon monoxide)

Fluid and electrolyte disturbances

Intoxication or withdrawal from substances

Hepatic encephalopathy

Medications (over-the-counter or prescribed)

Hepatolenticular degeneration (Wilson's disease)

Hypertensive encephalopathy

Hypotension

Porphyria

Uremia

The diagnostic criteria are based on the large body of evidence generated from adult studies, because few studies have focused on adolescents. The available evidence indicates that depression is much more likely in individuals who abuse drugs and alcohol, although little evidence supports any lasting neuropsychiatric syndrome that is related to substance use or abuse (Bukstein et al. 1992; Riggs et al. 1995). More than 50% of patients with severe alcohol abuse have symptoms of depression that may be indistinguishable from a primary mood disorder. The rapid resolution of these symptoms following

Table 6-9. Selected medications associated with mood symptoms

Depression

Mania

Cardiovascular

Anabolic steroids

Atenolol

Bronchodilators

Clonidine

Albuterol

Methyldopa

Terbutaline

Nadolol

Cardiovascular

Procainamide

Captopril

Propafenone

Clonidine withdrawal

Propranolol

Methyldopa

Chemotherapeutic agents

Chemotherapeutic agents

Amphotericin B

Procarbazine

Interferon

Corticosteroids

L-asparaginase

Decongestants

Procarbazine

Histamine-2 receptor antagonists

Vinblastine

Cimetidine

Vincristine

Psychiatric medications

Corticosteroids

Alprazolam

Prednisone

Amphetamines

Histamine-2 receptor antagonists

Antidepressants

Cimetidine

Bromocriptine

Immunosuppressants

Buspirone

Cyclosporine

Cyproheptadine

Tacrolimus

Isoniazid

Interferon

L-dopa

Isotretinoin

Lorazepam

Narcotics

Methylphenidate/stimulants

Methadone

St. John's wort

Oxycodone

Thyroid preparations

Oral contraceptives

Tolmetin

Statins

Yohimbine

Zidovudine

abstinence (2-14 days in adults) helps make the diagnosis (Schuckit 1982). The absence of a rapid resolution among adolescents makes the diagnosis more difficult and suggests a different etiological mechanism (Schuckit 1986). Identifying substance use in this population is important, because it is a risk factor for suicidal behavior and completed suicide (Brent et al. 1987).

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