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Depressive disorders in adults with Down syndrome

Authors:
A Bimonthly Mental Health/Mental Retardation Publication
January/February 1996 Volume 15 - Number 1
"[D]epression has been diagnosed in persons
with Down syndrome...[and]...reports demonstrate
that diagnostic validity is enhanced when
behaviors, rather than subjective feelings, are
emphasized as criteria and care is taken to rule
out all other medical and psychiatric conditions."
Co-Editors
Robert Sovner, M.D.
Anne DesNoyers Hurley, Ph.D.
Managing Editor
Maggie Zwilling
Contributing Editors
Joan Beasley, M.Ed. Mental Healthcare Policy
Betsey A. Benson, Ph.D. Psychosocial Interventions
William H. Benefield, Jr., Pharm.D. Drug Information
David Hingsburger, M.Ed. Sexuality
Andrew Levitas, M.D. Fragile-X Syndrome
Michael A. Lowry, Ph.D. Behavioral Psychology
James Luiselli, Ed.D. Clinical Behavior Therapy
Robert Pary, M.D. Down Syndrome/Aging
Al Pfadt, Ph.D. Community-Based Support Services
Stephen Ruedrich, M.D. Psychopathology
Judith J. Saklad, Pharm.D. Drug Information
Daniel J. Tomasulo, Ph.D. Psychotherapy
DEPRESSIVE DISORDERS IN ADULTS WITH DOWN SYNDROME
DENNIS E. MCGUIRE, PH.D.
BRIAN A. CHICOINE, M.D.
Depression is one of the most frequently diagnosed
psychiatric disorders for persons with mental retardation,3,17
especially those with Down syndrome.6,7,13,22 Prevalence
rates range from 6 and 13% for both groups and parallels
rates of depression for the general population.26 For adults
with Down syndrome, case studies describe depressive
symptoms often presenting as behavioral changes such as
withdrawal, loss of adaptive living skills, and observable
changes in mood. In addition to severe behavioral problems,
psychotic features are also a common manifestation of
depression.12,21,23,25 It is, therefore, critically important that
care providers recognize symptoms of depression and
consider this diagnosis prior to assuming that such individuals
may have Alzheimer’s disease or a psychotic disorder, for
both would lead to inappropriate treatment.
OVERVIEW OF THE DIFFICULTIES IN
DIAGNOSING DEPRESSION IN PERSONS
WITH DOWN SYNDROME
The diagnosis of depression is complicated for persons
with Down syndrome because of impaired verbal ability,
conceptual thinking, and overall cognitive functioning. They all
limit the individual’s participation in the psychiatric interview
process. When mental health clinicians meet with a patient to
formulate the diagnosis and treatment plan, they rely on
standard diagnostic criteria developed by the American
Psychiatric Association.1,2 Many of these criteria are based
upon the self-report of subjective feelings (such as verbal
expressions of sadness or worthlessness). It is, therefore, of
limited value in diagnosing persons who have diminished
ability for articulating thoughts and feelings.18 Also, care
providers, also unfamiliar with psychiatric symptomatology,
may be aware of critical changes, but not report them to
mental health or medical providers due to a lack of
understanding of the significance of such manifestations.16,19
The expressive and adaptive limitations of this
population may also increase the likelihood of misdiagnosis,
particularly of a psychotic disorder, because behavioral
changes may appear odd or worrisome to providers unfamiliar
with persons who have mental retardation.20 Hallucinatory-like
self-talk, skill loss or extreme withdrawal, which frequently
accompany a depressive disorder in persons with Down
syndrome, may be inaccurately diagnosed as a full-blown
psychotic disorder. For this population, diagnosis may also be
complicated by medical conditions such as hypothyroidism,
vitamin B12 deficiency, and Alzheimer's dementia, all of which
have symptoms that can mimic depression.10,11,14,22
Depression and Alzheimer’s Dementia
To further complicate matters, depression may coexist
with Alzheimer's dementia.11,14 In this case, prompt treatment
of depression will preserve functioning for some time, even
though a downhill course may be inevitable. The following
symptoms can be seen in both depression and Alzheimer's
dementia: loss of adaptive skills; disruption of sleep cycle;
appetite changes; apathy; moodiness; irritability;
aggressiveness; psychomotor agitation or retardation; and
memory loss. Alzheimer's dementia is particularly difficult to
rule out because there is no definitive test for this disorder,
and medical providers make the diagnosis by exclusion, i.e.,
they cannot find another cause for the noted problems.10,11
TABLE 1. PERCENTAGE OF DSM-IV SYMPTOMS OF DEPRESSION
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DISPLAYED BY SAMPLE (N=40)
DSM-IV Symptoms of Depression Percentage
Sadness or unhappiness (also described as loss of liveliness, humor, or spontaneity) 100%
Apathy, loss of interest/participation in activities including withdrawal from family and friends 100%
Loss of self-care or independent skills 70%
Noticeable change in eating habits; less\more 55%
Noticeable change in sleeping habits; less\more 73%
Psychomotor agitation 73%
Psychomotor retardation (activity slowdown) 83%
Loss of energy or overly fatigued 93%
Loss of focus, concentration, or task completion 83%
Self-absorbed, inattentive, or unresponsive (to people\things) 88%
Increase in irritated mood or moodiness 78%
Inappropriate fears or avoidances of people\things 60%
Psychotic features (extreme withdrawal, hallucinatory self-talk, etc.) 70%
Despite these difficulties, depression has been
diagnosed in persons with Down syndrome.12,21,23,25 These
reports demonstrate that diagnostic validity is enhanced when
behaviors, rather than subjective feelings, are emphasized as
criteria and care is taken to rule out all other medical and
psychiatric conditions. Additionally, these studies suggest that
differential diagnosis of depression and Alzheimer's dementia
can be accomplished by paying close attention to symptom
course. Depression tends to show an up-and-down pattern of
decline that with time and treatment will show improvement
and an eventual return to pre-morbid levels of functioning.
Symptoms of Alzheimer's dementia tend to fluctuate in the
early stages, but over time will show a progressive and
nonreversible pattern of decline.11,14,25
Co-morbid Psychiatric Disorders
Individuals who are suffering from depression may also
concurrently have another psychiatric disorder (called a co-
morbid condition). A large and growing body of literature has
shown a significant co-morbidity of depressive and anxiety
disorders.27,28 Symptoms of anxiety are common and
associated with depressive symptoms in the literature on
persons with mental retardation.3,12,17,21,25 Behavioral and
obsessive-compulsive disorders are also common disorders
found in the literature on people with mental
retardation.3,6,9,17,24
A SURVEY OF DEPRESSIVE DISORDERS
IN A SAMPLE OF PERSONS
WITH DOWN SYNDROME
In this article, we will review our clinic findings for 40
people with Down syndrome who were diagnosed with
depressive disorders and present five illustrative case
examples. These patients were followed in the Adult Down
Syndrome Center, a multidisciplinary clinic that follows 272
adults with Down syndrome.8 About one-third of these 272
patients use the clinic for their primary care. Another third
uses the clinic for yearly physical assessments and continues
to be followed by other primary care physicians. The
remaining patients come to the clinic for annual assessments
and use its resources for the diagnosis and treatment of
specific issues, such as depression. (For additional
information about the Center and its referral base see
Chicoine et al.8)
Study Sample
There were 40 patients in the sample, 23 men and 17
women. The average age was 31 with an age range from 19
to 58. These individuals were followed over a period of 36
months (from January 1992 to January 1995).
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TABLE 2. PERCENTAGE OF DSM-IV COMORBID DISORDERS DISPLAYED BY SAMPLE (N=40)
DSM-IV Co-morbid Disorders and Symptoms Percentage
Medical condition, hypothyroid disorder 22%
Medical condition, vitamin B12 deficiency disorder 2%
Anxiety disorder (agitation, body tension, hyperactivity, and
self-injurious behavior) 35%
Behavior disorder (verbal and physical aggression) 12%
Behavioral symptoms (verbal but not physical aggression) 22%
Obsessive-compulsive symptoms (most often as increase
in pre-existing compulsions) 33%
Diagnostic Criteria
Depression
A diagnosis of depression was made by the authors in
collaboration with psychiatric and other medical consultants.
A thorough medical examination was performed at the time of
diagnosis to rule out any medical cause of symptoms.8 The
criteria used were taken from the Diagnostic and Statistical
Manual of Mental Disorders, Third Edition - Revised (DSM-III-
R),1 adjusted for the adaptive and expressive limitations of this
population.16,19 The Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV),2 which was
available in the later months of the study period, was used as
well. The criteria used with this sample emphasized the use of
caregiver reports and observable behaviors and were similar
to those developed by Sovner19 for persons with mental
retardation.
Co-morbid Psychiatric Disorders
Due to the absence of adequate criteria in the literature,
the diagnosis of a co-morbid anxiety disorder was based on
an adaption of DSM-III-R criteria by the authors. The criteria
used in this sample was similar to a measure by Vitello and
colleagues24 for diagnosis of obsessive-compulsive disorder.
Vitello et al's measure relied on observed symptoms of this
disorder (such as irrational repetitious behaviors) because of
the difficulties in self-reporting of anxiety by persons with
mental retardation. Similarly, the criteria used to diagnose
anxiety disorders in this sample relied on observed indicators
of anxiety (such as agitation, restlessness and increased
body tension) rather than self-reporting of anxious thoughts
and feelings. Diagnosis was nonetheless complicated
because symptoms, such as agitation and restlessness,
overlap both depressive and anxiety disorders. Because of
this, an anxiety disorder was diagnosed only when the severity
and persistence of such symptoms were clearly noted by
caregivers and other observers.
Adaptive and Cognitive Function
No formal evaluation of cognitive functioning was
completed as part of the diagnostic evaluation. To assist in
clinical diagnosis, estimates of participants' pre-symptomatic,
adaptive living skills were obtained from caregivers.
Survey Results
Of the 40 individuals diagnosed with depressive
disorders, 16 were diagnosed with major depression alone, 14
with major depression and co-morbid disorders, and 10 were
diagnosed with mood disorder due to a general medical
condition. Nine of the latter ten had hypothyroidism, and one
other had a vitamin B12 deficiency. These individuals were
treated both for the medical condition and their depression
(which was treated with antidepressant therapy and supportive
counseling). Table 1 presents the symptoms displayed by our
patients. Table 2 displays the co-morbid problem findings and
Table 3 presents five illustrative case histories.
Depressive Symptom Presentation
For the 16 individuals diagnosed with major depression,
symptoms included fatigue or exhaustion, the appearance of
sadness (described also as a loss of liveliness, humor and
spontaneity), loss of concentration or task completion,
irritability and moodiness, increase in aggressive verbal
behaviors, agitation, sleeping disturbance, weight loss or gain,
self-absorption, inattentiveness to people and surroundings,
withdrawal, and a lack of interest or participation in all or most
activities. Psychomotor retardation often presented as a
general slowdown in all areas as well as extreme slowdown in
self-care activities such as dressing and eating.
Fearfulness was also reported, most often as a fear of
public places and strangers. Some increases in pre-existing
compulsive or ritualistic behaviors were also noted. For
several individuals, extreme sleep problems were also evident
including severe insomnia, reversals of day and night sleeping
patterns, and nocturnal activities such as roaming the house.
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TABLE 3. FIVE CASES OF DEPRESSION IN ASSOCIATION WITH DOWN SYNDROME
CASE DESCRIPTION COMMENT
Case 1. Major depression, single episode, mild to moderate degree of severity
Mr. A., a 43-year-old man living in a group home, became sullen, withdrawn and
unresponsive to fellow residents, staff and family members. He complained of
exhaustion and showed no interest in social and recreational activities. He had
difficulty concentrating and following through on tasks at work, resulting in a
noticeable drop in production. He had a decreased appetite and lost weight. Over the
course of the year he became more withdrawn and self-absorbed. He was negligent
about his own hygiene. His activity level slowed down, and he needed more and
more prompting to do even basic tasks. Staff in the group home noted the loss of a
long term caregiver and several recent deaths in his family as possible precipitants
to this depressive episode.
A course of individual treatment and consultation with caregivers, coupled with the
use of an antidepressant medication (paroxetine 20 mg daily ), resulted in a gradual
lifting of the depression and a return to normal functioning.
This individual presented with very
typical symptoms: weight loss, self-
absorption, exhaustion, social
withdrawal, and loss of concentration.
As the untreated disorder progressed,
the withdrawal and self-absorption
became more pronounced, and work
performance, as well as daily living
skills, declined.
Case 2. Major depression, more severe symptoms and psychotic features
In her third year in a food service job, Ms. B., a 24-year-old woman, became
extremely withdrawn, listless and self-absorbed. She would sit and stare as if in a
trance for hours. She exhibited what appeared to be hallucinations involving animated
and at times angry or indecipherable conversations with imaginary other(s). She was
moody, irritated and at times aggressive with her parents. Her movements and
activity level slowed drastically. She was fearful of being out in public. She stopped
going to her job, lost interest or motivation for self-care skills and for attending social
and recreational activities (despite a previously active social life).
When seen first at the Adult Down Syndrome Center, Ms. B. was on an
antidepressant - nortriptyline (Pamelor®) 80 mg daily and haloperidol (Haldol®) 1 mg
daily, which were prescribed by a previous psychiatrist. Both medications were
gradually discontinued because of extrapyramidal side effects (dry mouth, loss of
appetite, and urinary retention) and a sedation, which appeared to increase the
severity of her withdrawal and psychomotor retardation. A different antidepressant
was prescribed when she was seen at the clinic (paroxetine (Paxil®) 20 mg daily) and
it was better tolerated. This medication along with individual and family counseling
resulted in a gradual lifting of depressive symptoms. Ms. B. was also encouraged to
return to a work setting to facilitate the rehabilitative process and to relieve stress on
her family caregivers.
This individual displayed symptoms
which were severe and included
psychotic ones. In addition to
hallucinations, she developed fears
and a marked slowness that appeared
quite odd and bizarre. She did,
however, respond to antidepressant
therapy alone.
Case 3. Mood disorder due to general medical condition, hypothyroidism, more
severe symptoms and psychotic features
Ms. C., a 26-year-old woman, became increasingly withdrawn and self-absorbed.
Despite a previous good employment record she lost her job in a fast food restaurant
because of a lack of attentiveness to duties and because her self-talk was
increasingly noticeable to others. Her family noticed a similar absorption with her own
thoughts and self-conversations. Despite an active social life and good-natured
personality she became increasingly withdrawn, apathetic, listless and flat in her
affect. Her activities and movements were slowed dramatically. Her sleeping was
erratic and she gained weight. She became less attentive to her own hygiene and she
grew fearful of going to public places.
When she attended the Adult Down Syndrome Center, a hypothyroidism was
diagnosed. Treatment of this disorder with thyroid hormone therapy (Synthroid®) 0.1
mg daily was partially effective. She completely responded to treatment with
fluoxetine (Prozac®) 20 mg daily and supportive counseling for Ms. C. and her family.
Although the etiology of depressive
symptoms may have been due to a
medical condition (hypothyroidism),
the symptoms were very similar to
those displayed by persons with
depression, who were not found to
have a medical condition. In this case,
the symptoms were very severe and
included psychotic ones. Treatment of
the hypothyroidism as well as the
addition of an antidepressant and
supportive counseling, resulted in the
alleviation of symptoms.
TABLE 3. FIVE CASES OF DEPRESSION IN ASSOCIATION WITH DOWN SYNDROME (Cont.)
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CASE DESCRIPTION COMMENT
Case 4. Major depression and anxiety disorder
Ms. D., a 24-year-old woman and her ill elderly mother moved to another city to
be closer to an older sister. In the year after, she became extremely withdrawn with
extended periods of engaging in animated fantasies with “imaginary others.” She
slowed down dramatically in all activities including work and self-care. She became
uncharacteristically moody and irritated and had lost her liveliness and sense of
humor. She was agitated, restless, and could not seem to relax. She began to chew
on her fingers, causing unsightly cuts and sores. She showed an increase in
exhaustion and a pattern of sleeping days and staying awake at night. During this
period she was hospitalized with a bleeding ulcer which her doctor attributed to
stress.
Her family was reluctant to permit the use of antidepressant medication. Believing
that her symptoms were due in part to the loss of her former support network and a
over-sensitivity to her elderly mother’s illness, a nearby group home was located for
Ms. D. With much time and counseling she made new friends and developed new
interests in her new setting. This resulted in a gradual cessation of depressive and
anxiety symptoms.
The presentation of this individual was
very odd and bizarre. Her self-talk with
"imaginary friends" may have
developed to ease her loneliness. The
loss of self-care activities was
dramatic. Self-injury, such as chewing
on her fingers, also added to an
unusual presentation. The family’s
reluctance to use an antidepressant
may have prolonged symptoms.
Nonetheless, this case example shows
that situational changes should not be
overlooked when considering
treatment options. Also, a
spontaneous remission may have
occurred.
Case 5. Major depression, anxiety and behavior disorder
In his last year of school, and due to unknown causes, Mr. E. began to have the
same symptoms that he had displayed 10 years earlier following abuse from a fellow
student. For this second bout of symptoms, he became progressively tense, irritable,
and withdrawn. He refused to go to school in the mornings and would explode with
an outburst of yelling and throwing things when attempts were made to force him to
go. He began to masturbate openly, and to display a number of self-stimulating
behaviors such as rocking and hand-flapping. He became more ritualistic about the
exact order and placement of a large and growing number of items in his household.
In time his aggressive behaviors became more frequent and more assaultive of his
parents. His compulsive requirements for the placement of objects became more
rigid, his withdrawal from his parents and friends more extreme, his masturbatory
behavior more open and more frequent, and his anxiety, agitation, and self-
stimulatory behavior more pronounced.
As a result of the severity of symptoms, Mr. E. was hospitalized briefly in a
psychiatric hospital and treated with psychotropic medications (propranolol (Inderal®)
20 mg daily, Lithium 1200 mg daily; and lorazepam (Ativan®) 2 mg daily). In addition,
he had a carefully designed behavior management program. This treatment
continued after he was discharged.
Over time, his depressive and anxious symptoms have gradually dissipated and
his behavior problem has become more manageable. He recently transferred to a
residential facility where he continues to live successfully with only brief periods when
there is a recurrence of depressive, anxious or behavioral symptoms.
Depressive symptoms were quite
extreme and presented with severe
anxiety and behavioral disorders which
were not manageable in an outpatient
clinic. The severity of symptoms may
have resulted from the cognitive and
expressive language limitations of this
individual which may have prevented
him from conceptualizing and
expressing his depression in more
typical ways.
Five of the patients with major depression had a single
episode of mild severity. (See Case Example 1 in Table 3)
Their symptoms lasted an average of 12 months. Moderate
impairments in social relationships and mild impairments
inwork/school functioning or daily living skills were noted by
caregivers.
For the other 11 patients diagnosed to have major
depression, symptoms were more severe and often
accompanied by psychotic features. (See Case Example 2 in
Table 3) For these 11, caregivers reported that symptoms
lasted between 24 and 36 months, with an average of 28
months. They all had debilitating impairments in at least two
functional spheres of social relations, work/school, or activities
of daily living.
A common pattern of impairment included isolation from
social relationships, job loss or extended absence from work,
and a significant reduction in self-care and daily living skills.
For these 11 individuals, psychotic features which were
commonly observed included extreme withdrawal or trance-
like stupor, delusions, and hallucinatory-like conversations
with self and imaginary others (self-talk).
Self-talk was found to be common behavior for many of
the 272 adults with Down syndrome seen at the Center.
However, for the individuals diagnosed with depressive
disorders in the sample, incidents of such behaviors were far
more numerous, extreme, and more public. Observers also
noted these conversations to be more animated, angry in
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content and seemingly oblivious to the presence of others or
to social convention.
For the nine patients with a co-morbid anxiety disorder,
symptoms of the anxiety included agitation, increased body
tension, restlessness, hyperactivity, and mild to moderate self-
injurious behavior (including hand or finger biting, scratching,
hitting self, and hair pulling). Symptom severity was of
moderate severity for two and severe for the other seven.
(See Case Example 4 in Table 3)
For five others for whom anxiety and behavior
disturbances were co-morbid problems, symptoms of anxiety
again included agitation, increased body tension,
restlessness, hyperactivity, and mild to moderate self-injurious
behavior. Additionally all had a marked increase in compulsive
symptoms and a concomitant increase in a pre-existing
ritualized behavior. Self-stimulating behaviors such as rocking
and masturbation were also evident. Behavioral symptoms
included physically and verbally aggressive behaviors for all,
which were severe at times. Compared to the other 35
individuals who were diagnosed with a depressive disorder,
these five were described by caregivers as more intellectually
and functionally impaired. (See Case Example 5 in Table 3)
The ten persons diagnosed with a depressive disorder
due to a general medical condition, which has been reported
to cause depression,10,14 had depressive symptoms almost
identical to those individuals with major depression. (See
Case Example 3 in Table 3)
DISCUSSION AND CONCLUSIONS
The rate of depressive disorders in this sample (14.7%)
was slightly higher than the upper end of the range reported
in the literature for persons with mental retardation (6 -
13%).6,7,13,22 The higher rate may have been due to the
inclusion of persons with co-morbid psychiatric disorders and
depression secondary to medical conditions, who may have
been excluded in other studies. Although anxiety symptoms
were present for many of the patients in our sample, the
degree and severity of such symptoms merited a separate
diagnosis of an anxiety disorder in nine cases. For five
others, the severity of anxiety and behavior symptoms merited
a separate diagnosis along with depression.
As in other reports, depressive symptoms were most
often reported as behavioral changes. It is significant that 32
of the 40 persons with Down syndrome and major depression
had more severe, chronic and debilitating symptoms that were
often accompanied by psychotic features, and is consistent
with other reports.12,23,25 Despite the presence of psychotic
symptoms (such as hallucinatory self-talk and extreme
withdrawal), the diagnosis of a depressive disorder rather than
psychotic disorder, was warranted by DSM-III-R1 and DSM-IV2
criteria because depressive symptoms were predominant,
preceded and continued well after the cessation of psychotic
symptoms. Moreover, Sovner & Hurley20 have cautioned
against an overly hasty diagnosis of a psychotic disorder
when other disorders cannot be ruled out in this population
(such as depression). These authors recommended the use
of the term "psychotoform" for psychotic-like symptoms in
order to help promote the use of such medications as
antidepressants, which have a better risk-benefit ratio than
anti-psychotic medications.
Despite the severe and chronic course of many who
were diagnosed with depressive disorders in the sample, an
eventual pattern of improvement was shown, which does not
suggest Alzheimer's dementia. Still, in the absence of a
definitive test, Alzheimer's dementia cannot be totally ruled
out. These 40 individuals will continue to be followed
longitudinally at the Center to assess any significant re-
emergence of symptoms or losses in functioning.
The results of these clinical findings suggests that a
careful evaluation of behavioral changes, symptom course
and medical conditions should help clinicians to better
differentiate between depression, medical disorders,
Alzheimer’s dementia and psychotic disorders in this
population. These conditions often have similar symptom
presentations and yet have different treatments and
prognosis.
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Dennis E. McGuire, Ph.D. is the Coordinator of Family
Support Services for the Family Clinic, The Institute on
Disability & Human Development of the University of Illinois at
Chicago. Brian Chicoine, M.D. is the Medical Director of the
Lutheran General Adult Down Syndrome Center and on the
faculty of the Department of Family Practice at Lutheran
General Hospital, Park Ridge, Illinois.
... Depression is a common problem in these subjects and may present differently from the general population. [1][2][3][4] Subacute cognitive and language regression with adaptive behavior deterioration might be the most noticeable signs. Other features include psychomotor slowness, insomnia, and anorexia. ...
... [8][9][10] Other features included loss of interest in activities and subjects and anxiety. [1][2][3][4] Auto and heteroaggressive behaviors were reported in one study. 9 As far as we know, no previous studies focused on the association of psychotic features and depressive disorder in individuals with Down syndrome. ...
... Previous studies were unable to conclude the most suitable drugs and respective doses. 2,9,12 We chose fluoxetine because of the safety profile and approved use in the pediatric population by EMA. 24 On the other hand, fluoxetine inhibits the GIRK2 (a potential mechanism for treating depression) that is increased in the brain of patients with Down syndrome. ...
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Depression may manifest in different ways in people with Down syndrome. Cognitive regression and loss of adaptive skills could be the most noticeable signs. This report presents a 14-year-old female adolescent with Down syndrome and a proper premorbid function who developed progressive cognitive regression over four months. Additional symptoms consisted of irritability, psychomotor slowness, a deficit in social interaction, alienation, loss of interest, and permanent, incoherent, and implausible self-talk (with persecutory delirium). No signs of sadness were noted. The patient was diagnosed as having a major depressive disorder with moodincongruent psychotic features. Organic causes were excluded. After starting treatment with fluoxetine 50 mg/ day and aripiprazole 10 mg/day, an improvement was observed over a 12 week period. By presenting this case, we aim to highlight the specific challenges regarding the diagnosis and treatment of Down syndrome adolescents and young adults presenting with subacute cognitive regression. Keywords: Adolescent; Aripiprazole/therapeutic use; Depressive Disorder/diagnosis; Depressive Disorder/ therapy; Down Syndrome/psychology; Fluoxetine/ therapeutic use; Neurobehavioral Manifestations; Regression, Psychology
... Depression is a common problem in these subjects and may present differently from the general population. [1][2][3][4] Subacute cognitive and language regression with adaptive behavior deterioration might be the most noticeable signs. Other features include psychomotor slowness, insomnia, and anorexia. ...
... [8][9][10] Other features included loss of interest in activities and subjects and anxiety. [1][2][3][4] Auto and heteroaggressive behaviors were reported in one study. 9 As far as we know, no previous studies focused on the association of psychotic features and depressive disorder in individuals with Down syndrome. ...
... Previous studies were unable to conclude the most suitable drugs and respective doses. 2,9,12 We chose fluoxetine because of the safety profile and approved use in the pediatric population by EMA. 24 On the other hand, fluoxetine inhibits the GIRK2 (a potential mechanism for treating depression) that is increased in the brain of patients with Down syndrome. ...
Article
Full-text available
Depression may manifest in different ways in people with Down syndrome. Cognitive regression and loss of adaptive skills could be the most noticeable signs. This report presents a 14-year-old female adolescent with Down syndrome and a proper premorbid function who developed progressive cognitive regression over four months. Additional symptoms consisted of irritability, psychomotor slowness, a deficit in social interaction, alienation, loss of interest, and permanent, incoherent, and implausible self-talk (with persecutory delirium). No signs of sadness were noted. The patient was diagnosed as having a major depressive disorder with mood-incongruent psychotic features. Organic causes were excluded. After starting treatment with fluoxetine 50 mg/ day and aripiprazole 10 mg/day, an improvement was observed over a 12 week period. By presenting this case, we aim to highlight the specific challenges regarding the diagnosis and treatment of Down syndrome adolescents and young adults presenting with subacute cognitive regression.
... Pary and Loschen, in their review of the 22 research, found a com bined frequency of occurrence for psychotic sym ptoms in 54% of cases with mood disorders in Down syndrom e. McGuire and Chicoine studied 40 patients seen 16 over a period of three years. Patients were 23 m ales, 17 ...
... Mood 30 congruent hallucinations and delusions were well represented in the cases as well as hallucinations and psychotic behavior during a major depressive episode. Reprimands and content 4,12,16,26,27,30 related to negative events such as war or death occurred. McGuire and Chicone reported two 16 patients as case examples of their larger cohort who also had obsessional slowness. ...
... Reprimands and content 4,12,16,26,27,30 related to negative events such as war or death occurred. McGuire and Chicone reported two 16 patients as case examples of their larger cohort who also had obsessional slowness. The first, Ms. B, a 24-year-old wom an with depression, p r e s e n t e d w i t h e x t r e m e wi t h d r a w a l , hallucinations and indecipherable conversations with imaginary others, and obsessional slowness. ...
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Individuals with Down syndrome are at a lower risk for psychiatric disorders compared to other individuals with intellectual disability. However, a literature review found a number of cases of psychiatric illness that included the presence of hallucinations and delusions. In order to determine whether this is unique to Down syndrome, a retrospective chart review compared 53 patients with Down syndrome against a matched group of 53 patients with intellectual disability of other etiologies. There was no significant difference between the groups for psychotic symptomatology. Those with Down syndrome were less likely, however, to present with aggression or self-injury.
... at ten tion de fi cit hype rac ti vity di sor der -ADHD), по ре ме ћа ја у ви ду про ти вље ња и пр ко са или агре сив ног по на ша ња [11], док се са од раста њем по ве ћа ва број и уче ста лост ин тер на ли зо ва них про бле ма и по ре ме ћа ја ко ји се нај че шће ма ни фе сту ју симп то ми ма по вла че ња (пре фе ри ра ње са мо ће, тај нови тост, од би ја ње ко му ни ка ци је) и де пре си је. Симп томи по вла че ња се ис по ља ва ју код 63-75% адо ле сце на та [9], док се кли нич ка сли ка де пре си је раз ви је код 6-13% осо ба са ДС [12]. Де пре си ја код од ра слих че сто ко ег зисти ра са де мен ци јом Ал цхај ме ро вог ти па, при че му се обе кли нич ке сли ке мо гу ис по љи ти на сли чан на чин: сла бо рас по ло же ње, со ци јал но по вла че ње, ан хе до ни ја, сма њен апе тит, по ре ме ћај спа ва ња, про па да ње адаптив них ве шти на, му ти зам, агре сив но по на ша ње/тантру ми, ири та бил ност и плач љи вост [12]. ...
... Симп томи по вла че ња се ис по ља ва ју код 63-75% адо ле сце на та [9], док се кли нич ка сли ка де пре си је раз ви је код 6-13% осо ба са ДС [12]. Де пре си ја код од ра слих че сто ко ег зисти ра са де мен ци јом Ал цхај ме ро вог ти па, при че му се обе кли нич ке сли ке мо гу ис по љи ти на сли чан на чин: сла бо рас по ло же ње, со ци јал но по вла че ње, ан хе до ни ја, сма њен апе тит, по ре ме ћај спа ва ња, про па да ње адаптив них ве шти на, му ти зам, агре сив но по на ша ње/тантру ми, ири та бил ност и плач љи вост [12]. ...
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Challenging behavior in individuals with mental retardation (MR) is relatively frequent, and represents a significant obstacle to adaptive skills. The frequency of specific forms and manifestations of challenging behavior can depend on a variety of personal and environmental factors. There are several prominent theoretical models regarding the etiology of challenging behavior and psychopathology in persons with MR: behavioral, developmental, socio-cultural and biological. The biological model emphasizes the physiological, biochemical and genetic factors as the potential source of challenging behavior. The progress in the field of genetics and neuroscience has opened the opportunity to study and discover the neurobiological basis of phenotypic characteristics. Genetic syndromes associated with MR can be followed by a specific set of problems and disorders which constitutes their behavioral phenotype. The aim of this paper was to present challenging behaviors that manifest in the most frequently studied syndromes: Down syndrome, Fragile X syndrome, Williams syndrome, Prader-Willi syndrome and Angelman syndrome. The concept of behavioral phenotype implies a higher probability of manifesting specific developmental characteristics and specific behaviors in individuals with a certain genetic syndrome. Although the specific set of (possible) problems and disorders is distinctive for the described genetic syndromes, the connection between genetics and behavior should be viewed through probabilistic dimension. The probabilistic concept takes into consideration the possibility of intra-syndrome variability in the occurrence, intensity and time onset of behavioral characteristics, at which the higher variability the lower is the specificity of the genetic syndrome. Identifying the specific pattern of behavior can be most important for the process of early diagnosis and prognosis. In addition, having knowledge about behavioral phenotype can be a landmark in the creation of targeted treatment strategies for individuals with a specific genetic syndrome.
... Individuals with DS may frequently also experience obsessions, compulsions, and severe generalized anxiety as a result of major depression [20]. Some may further exhibit psychotic or catatonic-like characteristics, making the detection and treatment of their depression more difficult [20,27]. Medical conditions such as obstructive sleep apnea (OSA) should be ruled out in individuals presenting with immense fatigue and daytime somnolence, as OSA may mimic depressive symptoms [20,28]. ...
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Depression has been commonly treated with psychotherapy and/or pharmacotherapy for several decades. Ongoing research in the field has suggested promise for behavioral activation (BA), a form of psychotherapeutic intervention, as a means of increasing engagement in adaptive activities and developing skills to counter avoidance in individuals suffering from depression. In this case report, we present the treatment course of BA for an adolescent with Down syndrome (DS), presenting with depression. A multidisciplinary approach was utilized in developing a personalized management plan for the patient since the initial presentation. Sessions at the outpatient psychiatry clinic alternated between in-person visits and virtual ones, due to circumstances associated with physical distancing with the COVID-19 pandemic. Parents were included as integral parts of the management plan, and education, strategic implementation of BA, and barriers to care were discussed extensively to support the adolescent through the course of her treatment. Within 6 weeks of introducing BA, positive outcomes were noted in the patient, with the resolution of her clinical depression. In this report, we discuss BA further as a potentially effective therapeutic approach to the treatment of depressive symptoms in children and adolescents with DS and intellectual disabilities.
... However, psychopathology is less frequent in DS compared to other children with intellectual disability [3]. The prevalence of depression in DS is 11%; DS is also a risk factor for developing depression [38,39]. Depression frequency is lower in children and adolescents with DS than adults [40]. ...
Article
A deterioration in some of their cognitive functions and adaptive skills has been observed in adolescents and young adults with Down's syndrome (DS), which is similar to that observed in individuals who suffer from Alzheimer's disease, although at much earlier ages. Little is known of the etiology of these changes. In this work, 3 cases are presented on 3 young adults with DS, who presented with a deterioration in their cognitive functions and a loss of, previously well attained, functional skills. Some medical and psychological risk factors that could be associated with this regression are examined. In all the cases, the loss of skills was associated with anxiety and depression symptoms.
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Aim: To ascertain the effects of 21 weeks of circuit training, including plyometric jumps, on cardiorespiratory fitness of youths with Down syndrome (DS). Methods: Twenty-seven children and adolescents aged 10 to 19 years with DS participated in this study and were divided in two groups: exercise (EXE, n = 14) and control (CON, n = 13). Work time, peak values of oxygen consumption, respiratory exchange ratio, heart rate and minute ventilation of the participants were measured in pre- and post-training moments with a graded exercise treadmill test. Results: EXE group increased all their cardiorespiratory parameters compared to baseline after 21 weeks of training (all p<.05). Additionally, and despite having similar pre-training values, EXE group showed higher values than CON group in all cardiorespiratory parameters after training (all p<.05). Conclusion: It may be concluded that youths with DS can achieve improvements in several cardiorespiratory parameters when performing 21 weeks of training including plyometric exercises.
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A deterioration in some of their cognitive functions and adaptive skills has been observed in adolescents and young adults with Down's syndrome, which is similar to that observed in individuals who suffer from Alzheimer's disease, although at much earlier ages. Little is known of the etiology of these changes. In this work, 3 cases are presented on 3 young adults with Down's syndrome, who presented with a deterioration in their cognitive functions and a loss of, previously well attained, functional skills. Some medical and psychological risk factors that could be associated with this regression are examined. In all the cases, the loss of skills was associated with anxiety and depression symptoms.
Article
To ascertain the effects of 21 weeks of circuit training, including plyometric jumps, on cardiorespiratory fitness of youths with Down syndrome (DS).
Genetic disorders are responsible for nearly 50 percent of the half million moderately and severely mentally retarded. These include chromosomal abnormalities, those due to single genes, and others resulting from a combination of genetic and environmental factors. With the exception of specific metabolic diseases, most are not treatable so that prevention by genetic counseling and prenatal diagnosis becomes imperative. Neither of these can be accomplished without an accurate diagnosis underlining the importance of a diagnostic evaluation for all moderately and severely retarded individuals
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The total number of adults with Down's syndrome living in Leicestershire, ascertained by widespread enquiry, was found to be 378. Of these, 371 were matched with adults with mental handicap due to other pathologies, on the basis of age, sex, and type of residence. Those with Down's syndrome were found to have a different spectrum of mental disorders from those without the syndrome. In particular, Down's syndrome patients were more likely to have been diagnosed as having depression and dementia; the controls were more likely to have been diagnosed as suffering from conduct disorder, personality disorder, or schizophrenia/paranoid state. The same proportion of each group had been given a diagnosis of autism.
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The relation between dementia and depression in 61 adults with Down syndrome or 43 adults with mental retardation due to other causes was examined. Age-matched participants, ranging in age from 20 to 60 years, received a neuropsychological battery to assess declines in functioning and caregiver report measures to assess adaptive behavior and depression. Eight adults with Down syndrome had both depression and declines in functioning. No adults with mental retardation due to other causes had declines. Greater severity of depression was related to lower MA, poorer memory, and lower adaptive functioning in adults with Down syndrome only. Results suggest that dementia and depression are associated in Down syndrome but not in mental retardation due to other causes.