WI Alliance of Child Psychiatry and Pediatrics CASE STUDY. Mood Disorders. James A. Meyer MD Adolescent Medicine Marshfield Clinic

Transcription

1 WI Alliance of Child Psychiatry and Pediatrics CASE STUDY Mood Disorders James A. Meyer MD Adolescent Medicine Marshfield Clinic

2 Disclosure Statement I, James Meyer, M.D., do not have any relevant financial interest or other relationship(s) with a commercial entity producing health-care related product and/or services. I will indicate during this presentation when a medication use or dosage is other than an FDA approved treatment.

3 Case: Laura Presents with her mom at age 11 for acute evaluation of escalating behavior concerns over the past 2 years. Relevant PMH and FH

4 Case: Laura Social HX Lives with her mom (store cashier) and dad (factory worker) with one sister age 8yrs. No recent major changes within the home but -financial stresses -marital discord (parents fight a lot)

5 Case: PMH Laura Normal prenatal and peri-natal course. Had colic until 4 months of age. Had difficulty with new adjustments: daycare, first day of school. DX ADHD with oppositional features age 5. Treated with Adderall and clonidine by Developmental/Behavioral Peds to age 8. Meds helpful but did not keep follow up appointments for meds or counseling (Perceived as not doing good parenting).

6 Case: Laura FH Dad felt to have ADHD but never formally diagnosed or treated- impulsive and cannot sit still. Long standing concern with alcohol use 3 rd OWI. Mom diagnosed with bipolar disorder not on meds right now. Sister has aniety.

7 Case: Laura Dramatic, sudden but episodic mood changes: etremely irritable, angry, and out of control. Occur several times each week with Laura seeming sad or irritable in between episodes Triggered by minor events like being asked to help pick up after dinner, not doing well on a video game, sharing with her sister, etc. Everyone walks on egg shells around her. Has chased sibling with a knife around the house and thrown and broken things that she values. Peers have commented about her nasty temperament as has the school.

8 Case: Laura 5 th grade with stable grades and not missing school but not wanting to go if an upsetting episode occurred prior to the school day. Some issues with focus and at times distracted. Recent conflicts with some friends who seem to be pulling away. Perceived as head strong. No definite bullying and some comments about her being the bully. Teachers describe as not a happy camper always negative yet not overtly sad. No ecess caffeine or suspected alcohol or drug use.

9 Case: Laura No one understands me. Everyone is mean to me. No suicidal thoughts but may make comments about no reason to live when she is in the middle of an episode. Sleep is ok without clear obstruction. Diet is typical for 11 yo. No acknowledged abuse.

10 Case: Laura No periods of frank mania but thoughts are seemingly racing when upset and with over ecitement No ecess self confidence No lack of need for sleep.

11 Primary Care Screening for Depression: Two-Question Case-Finding Instrument During the past month, have you often been bothered by feeling down, depressed, or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things?

12 DEPRESSION DX Mnemonic Sadness and/or irritable plus: S- change in SLEEP I- loss of INTEREST in usual activities G- self critical and feelings of GUILT E- change in ENERGY level C- problems with CONCENTRATION A- change in APPETITE P- PSYCHOMOTOR agitation or slowing S- thoughts of SUICIDE or self harm

13 Case: Laura Well groomed but dressing older than her age. Boisterous and uninhibited. Argues continuously with her mom during the visit. Normal eam. NL BMI. No suggestion of anemia, thyroid dysfunction, obstructive nasal breathing or other medical conditions. No labs deemed necessary but will consider if not doing better: CBC with differential, ferritin, TSH, MPC.

14 Laura s Total 9 Total Score and degree of depression: 1-4 minimal 5-9 mild moderate moderate to severe severe

15 MOOD DISORDER QUESTIONAIRE (MDQ) Total yes responses of 7 or > of 13 items in question 1 Positive response to question 2 Laura s total= 9 of 13 Indicated mod. to marked problems

16 Major Depressive Episode Dysphoric mood, irritability or loss of interest/pleasure in usual activities. At least 4 of the following: -altered appetite -disturbed sleep -psychomotor retardation or agitation -loss of energy -anhedonia -feelings of self reproach/guilt -altered mentation (concentration) -thoughts of suicide Absence of other mental health DX or organic disease.

17 CASE: Laura Parent Achenbach CBC (combined) Competence scale marginal (T score 64) for school, activities, and social. Syndromic Scales elevated with T score of 75 for aniety/depressed and aggressive behavior. Scores on attention problems, rule breaking, social problems and thought problems at 63. Normal T score on somatic symptoms DSM Oriented Scales elevated for affective 70, oppositional 75 and ADHD 65 but normal aniety somatic and conduct Increased eternalizing T score of 75 T score median 50, Standard deviation of 10. T score of 67 top 5%.

18 Disruptive Mood Dysregulation Disorder (DSM-5) DMDD is defined by the following criteria: Severe temper outbursts at least three times a week, out of proportion to the situation and inconsistent with the child s developmental level. Sad, irritable, or angry mood almost every day. Trouble functioning in more than one setting which can include home, school, and/or with friends. The child must be at least si years old, and symptoms must begin before age ten. Symptoms must be present for at least one year.

19 Case: Laura Diagnosis- Disruptive Mood Dysregulation Disorder with HX ADHD Treatment 1) Counseling Formal counseling is needed ideally cognitive behavioral therapy (more positive thoughts and actions) Stop and think before escalating actions, speaking, etc. Sleep hygiene, diet, fluids, eercise. 2) Medication Phone consultation with Child Psychiatrist. Started guanfacine 0.5mg bid

20 Case: Laura Treatment Plan Discuss: Aspects of medication use: -Adequate hydration. -Aids sleep -Fairly quick calming response for aggression, irritability -Use lowest effective dose to control symptoms -Titrate upward slowly and may need tid dosing. Consider long-acting Intuniv if helpful. Common side effects -sedation -orthostatic light-headedness/lower blood pressure.

21 Case: Laura Follow Up Follow up- 1) Phone update in 1 week to screen for: - basic side effects: ecess sedation, dizziness. - compliance - counseling appointment has been scheduled - Child Psychiatry appointment is scheduled 2) Appointment in 3-4 weeks: -All agree that she is better-less irritable. -Not dizzy. -No acknowledged side effects like sedation.

22 Case: Laura Follow Up Saw Child Psychiatrist who recommended continuing this medication and counseling as having no further threatening episodes. Over time switched to once daily Intuniv. At 6 months added Strattera (atomoetine) for affective and ADHD symptoms. Started at 10mg titrated up to 40mg. Appears to be doing well on combination.