Child Depression and Anxiety Care Essentials

Transcription

1 Child Depression and Anxiety Care Essentials Robert Hilt, MD, FAAP Associate Professor Psychiatry, U of Washington Medical Director, Partnership Access Line and 2 nd Opinion Consults Disclosures In the past 12 months, I have had not had any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial service(s) discussed in this activity. I will discuss unapproved/investigative uses of medications in my presentation. 1

2 Why Depression and Anxiety? Common problems Anxiety point prevalence of 2 4% Depression point prevalence 2% (0-12) to 6% (13-18) Primary Care is front line in Detection Establishing expectations Starting the treatment plan Costello, Egger, and Angold 2004 Lewis, 2002; Weiner 2004 Mood/anxiety problems often masquerade as medical Physical complaints often the lead Generalized Anxiety Disorder muscle tension insomnia physical sense of restlessness Depression appetite changes sleep changes fatigue 2

3 Perspective on Somatic Complaints Of adolescents reporting somatic symptoms Organic causes found just 10-15% of the time for: Headaches Nausea Chest pain Abdominal pain Fatigue Silber TJ, Pao M, 2003 K Kroenke, AD Mangelsdorff 1989 ANXIETY 3

4 Anxiety Can Be Normal Fear and worry happen in normal children Like fear of the dark Fear of strangers Anxiety has a useful function keeps us safe important part of social norms When is Anxiety a Problem? When unable to function normally Avoiding normal activities, like school When a disproportionate response to stress or life circumstance 4

5 The Basic Anxiety Cycle Trigger i.e. a separation, or seeing feared object Anxiety builds Escape behavior i.e. cling to parent, or run away Immediate relief Anxiety is reinforced by that escape relief How do you look for Anxiety? Can have a few questions to routinely ask: Do you have worries/fears that keep you from doing things you want to do? A rating scale can help: General Screener PSC-17 CBCL or BASC Specific Screener SCARED, Spence Anxiety Scale, MASC 5

6 PSC-17 Internalizing Depression Anxiety Attention Externalizing ODD Conduct No fee for use By Gardner et all 1999, from PSC by Jellinek M et al 1988 Formatting by SCARED Developed by B. Birmaher, et. al 1997 Available free for clinical use through wpic.pitt.edu 6

7 Using Rating Scale Scores Only as good as the information input Positive review of systems Adolescent who denies everything Imperfect sensitivity/specificity SCARED= 71% sensitivity, 67% specificity A high screening score can at least stimulate a pertinent discussion Birmaher, Brent, Chiappetta,, et al 1999 Child Anxiety Comorbidities ~80% have another psychiatric diagnosis Around 50% have 2 or more anxiety disorders Up to 50% also have Depression Up to 20% also have ADHD If you find one problem, may be other issues Kendall, Brady and Verduin 2001 Lewinsohn, Zinbarg,, Seeley et al, 1997 Bowen, Chavira, Bailey, et al

8 Many Flavors of Anxiety Separation Anxiety Generalized Anxiety Panic Disorder Social Phobia Specific Phobias Obsessive Compulsive Disorder Post Traumatic Stress Disorder Unspecified Anxiety Disorder Unspecified Anxiety Disorder Why it is useful The different anxiety disorders have similar therapy approaches o Usually CBT is best The different anxiety disorders have similar medication approaches o Usually SSRI s are best Unspecified Anxiety accommodates the developmental changes in expression of anxiety o Separation anxiety Social Phobia o Specific phobia GAD 8

9 Childhood Anxiety (CAMS) Multisite RCT, funded by the NIMH separation anxiety generalized anxiety social phobia 488 children between the ages of sessions of CBT (Coping Cat) Sertraline (average final dose by week 8 was mg/day) Combination treatment Placebo Walkup JT, Albano AM et al, 2008 CAMS Results: Treatment % of Responders (CGI) CBT plus Sertraline 81% CBT 60% Sertraline 55% Placebo 24% *much or very much improved on CGI 9

10 What is CBT Anxiety Treatment? CBT = Cognitive Behavioral Therapy Assumes there are errors in thoughts and behavior choices leading to symptoms Get back on the horse Exposure to/unlearning the fear Downside of CBT Trouble finding a CBT therapist Child willingness/ability to engage in CBT How does Anxiety CBT work? 1) Give psychoeducation about disorder 2) List child s hierarchy of fears 3) Develop a Graded Exposure plan Example: separation anxiety First tolerate being at school with parent Then tolerate parent sitting outside classroom door (visible) Then tolerate parent sitting down the hall (not visible) Child cannot maintain panic, so accommodates 10

11 Obsessive Compulsive Disorder (OCD) 0.3 to 3% of kids have it 1/3 of adults with OCD report started in childhood Excessive cleaning 85% Repeating rituals 51% Checking behavior 46% Highly biologically driven high heritability very low placebo response rates Rutter, 1970; Zohar. 1992; Swedo et al, 1989; NIMH Pediatric OCD Treatment Study Condition CBT+ Sertraline Remission Rate 54% 1.4 CBT 39% 0.97 Sertraline 21% 0.67 Placebo Pill 4% N/A Effect Size POTS JAMA,

12 SUGGESTED SSRI DOSAGES--ANXIETY Medication Usual Adolescent Starting Dose Increase Increment (after 4-6 weeks) Max Dosage Youth RCT anxiety Fluoxetine 10mg/day 10-20mg 60mg Yes OCD Sertraline 25mg/day 25-50mg 200mg Yes OCD Fluvoxamine 25mg/day 50mg 300mg Yes OCD Citalopram* 10mg/day 10-20mg 40mg Yes Youth FDA Approval --First line recommendations appear in bold --If a pre-adolescent, consider decrease these dosages by ~½ to 1/3 rd * Citalopram is not approved for child anxiety disorders Treating Anxiety with Other Medications? Tricyclic Antidepressants (TCA s) Negative RCTs in children (for non-ocd anxiety) Not generally recommended for anxiety Exception: specialists will consider clomipramine for treatment resistant OCD Berney et al 1981, Klein et. al

13 Other Medications for Anxiety? Benzodiazepines* can be appropriate in short term 2 negative RCT s for anxiety small samples, short duration, low dosages short acting, high potency agents not recommended for long term use (triazolam, alprazolam, lorazepam) If need to use, prefer longer acting like diazepam or clonazepam *not FDA approved for anxiety in kids Simeon et al, 1992; Graae et al, 1994 Other Anxiety Medications Buspirone* no RCT s in kids, positive results for adults open label studies suggest can have a role Beta Blockers* no RCT s in kids, positive results for adults Consider for performance anxiety Consider if agitation or akathisia after brain injury *Not FDA approved for anxiety in kids 13

14 Other Anxiety Medications Antihistamines* use for short term insomnia, anticipatory anxiety no controlled trials in kids hydroxyzine an approved anxiety treatment in adults Mirtazapine* open label study support in adults with GAD, panic no controlled trial support in kids consider if need sedation and appetite stimulation *Not FDA approved for anxiety in kids Other Anxiety Medications Venlafaxine* 2 different RCT s combined into one report with 320 children in order to show a benefit (i.e. 69% vs 48% CGI<3) side effect profile makes this a 2 nd tier option Buproprion* no controlled trials on anxiety adult open trials suggest can be helpful some patients experience anxiety as side effect *Not FDA approved for anxiety in kids MA Rynn et al,

15 Summarized Anxiety Recommendations Remember to look for anxiety problems o Rating scales can help Make a therapy referral o CBT preferred where available Consider SSRI if: o Not improving with CBT o Moderate to severe symptoms o Fluoxetine, & Sertraline are first line options o each has 3 RCTs showing they benefit child anxiety o We will discuss the black box later... Other Resources to Offer (these contain DIY CBT advice) Books that parents may find helpful: Freeing your Child from Anxiety (2004), by Tamar Chansky, PhD. Helping Your Anxious Child (2008), by R Rapee PhD., A Wignall DPsych, S Spence PhD., V Cobham PhD., and H Lyneham, PhD. Worried No More, 2 nd Ed (2005), by Aureen Pinto Wagner, PhD Talking Back to OCD (2006), by John March MD Freeing Your Child from Obsessive-Compulsive Disorder (2001), by Tamar Chansky, PhD Books that children may find helpful: What to Do When You Worry Too Much (2005), by Dawn Huebner, PhD. What to Do When You Are Scared and Worried (2004), by James Crist, PhD. 15

16 MOVING ALONG TO DEPRESSION... Major Depression--Diagnosis 2 weeks of depressed mood plus 4 of the following changes (5 if mood is just irritable): Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicidality 16

17 Clinical judgment trumps all You may judge child has Unspecified Depression even if not all criteria are met Enough basis to initiate treatment Rating scales exist to help you Broad Screening PSC-17, SDQ Others like CBCL, BASC for a fee Narrow Screening/Diagnostic aide PHQ-9 for adolescents SMFQ for kids over age 6 Others like CDI, CDRS-R for a fee Can measure response to treatments 17

18 SMFQ Relatively depression specific 60% sensitivity 85% specificity Tested for age 6 and up No fee for use By Angold and Costello, 1987 Free download at mfq.html Ask About Suicidality Part of every depression evaluation Start broad Ever wish that you weren t around? Ever thought about killing yourself? Get specific In the past month, have you thought about killing yourself? Have you made any plans for how you would kill yourself? What would you do? 18

19 Why Ask? Because Suicidality in Young People is Common National Survey of High School Students Wyoming Suicide data below: Seriously Considered % 17.4% 17.8% 17.3% 17.4% Made a Plan 15.8% 15.7% 17.8% 15.3% 14.2% Made suicide attempt 9.1% 8.7% 10.5% 9.4% 11.3% (Above rates are about 2 percentage points above national average) YRBS by CDC Self Harm in Teenagers Is Common (~15% of all US teenagers) Self harm is often planned out >½ plan more than an hour in advance It happens at home ¾ of the time Doctors rarely know about it (<14%) Friends/family do know about it (~75%) Occurrence is rarely influenced by substance abuse N Madge, E Hewitt et al, 2008 From Klonsky ED and Muehlenkamp JJ

20 Why do kids self injure? 1. Affect Regulation (AKA distress tolerance ) ---clearly the most common reason 2. Self Punishment 3. Interpersonal Influences 4. Anti-dissociation 5. Anti-suicide 6. Sensation Seeking 7. Reinforce Interpersonal Boundaries From Klonsky ED and Muehlenkamp JJ 2007 What Can You Do for Child Depression? Schedule frequent follow up visits Prescribe behavioral activation, exercise Recommend increased peer interactions Recommend support groups, if available Encourage good sleep hygiene Encourage reduced stressors, if possible ~¾ of youth suicide attempts immediately triggered by an interpersonal conflict Vitello, et al J Clin Psych

21 What You Can Do (continued) Temporarily remove any guns, dangerous pills from the home Lowers impulsive suicide risks Offer a crisis line number 800-SUICIDE or TALK if no local options Moderate/severe cases refer sooner than later to counseling Provide psychoeducation Provide an Information Handout (Example from palforkids.org) (Example from Glad-PC ) 21

22 Management Follow up appointment in 2-4 weeks to check if situation is getting worse Staying engaged is a valuable intervention Repeating a rating scale helps monitor Mild cases not improving on their own become referral candidates for counseling MDD Treatment Psychotherapy: a safe first line intervention Randomized controlled trials support: CBT: Cognitive Behavior Therapy IPT: Interpersonal Therapy CBT Cognitive distortions i.e. everything goes wrong for me Behavior that impacts our feelings i.e., physical inactivity lowers mood Usu. requires homework between sessions 22

23 Other Therapies Supportive therapy (often done, less effective than CBT) Play therapy (not as well studied, requires a very skillful therapist) Psychodynamic therapy All therapy is less effective if: Hopeless Suicidal Active family conflict/abuse Weak alliance with therapist Brent et al, 1997 AACAP Practice Parameter 2007 Depression Medications 23

24 MDD Medications Medications in Kids Positive Randomized Controlled Trials (that had a positive result on their primary outcome variable) 3 fluoxetine 1 fluoxetine (continuation phase) 1 sertraline* 1 citalopram* 1 escitalopram CGI: a clinician rates their global impression of improvement compared to baseline (Guy M, 1976) much or very much improved as primary outcome in psychiatric trials Was primary outcome for all but the citalopram trial above * Not FDA approved for depression in kids % Response Rates in those Positive Adolescent Depression Trials Response rate (CGI 2) 3 fluoxetine 52-61% vs. placebo 33-37% 1 sertraline 63% vs. placebo 53% 1 citalopram* 47% vs. placebo 45% 1 escitalopram 64% vs. placebo 53% *Note the CGI was not the primary outcome variable. Wagner et al 2003, 2004; March et al, 2004; Emslie et al 1997, 2002,

25 Understanding The Trials High placebo response rates Placebo group gets frequent care appointments with a skilled child psychiatrist placebo is not equivalent to no treatment Expect spontaneous remission when treating mild depression Design bias in pharma sponsored trials TADS Treatment Treatment of Adolescent Depression Study 439 adolescents 12 week treatment Moderate to severe depression ~30% with suicidality More than half had comorbid psychiatric illness Community and academic centers Randomized to: fluoxetine fluoxetine plus CBT CBT alone placebo TADS,

26 TADS Medication Protocol Starting dose fluoxetine 10mg Week two, increased to 20mg (if no side effects) Dose could be increased at weeks 4, 6, 9 and 12 if still significant symptoms Mean final dose was ~30mg/day TADS Results Treatment Response Rate (CGI 2) Fluoxetine plus CBT 73% Fluoxetine 62% CBT 48% Placebo 35% Suicidal events decreased with all active treatments At 36 week follow up more common with fluox alone (14%) than Combination (8%), or CBT (6%) 26

27 TADS response rates (CGI equalize over time (CGI 2) Week # Fluox. + CBT Fluox. CBT Placebo Placebo/ Open 12 73% 62% 48% 35% 18 85% 69% 65% 67% 36 86% 81% 81% 82% (Fluoxetine improved their depression more quickly) But Aren t SSRI s Dangerous for Kids? FDA Black Box in 2004, based on 24 studies For all diagnoses suicidality RR 1.95 (95%CI= ) T Hammad, T Laughren,

28 SSRI suicidality differences Risk Ratio 95% confidence interval Venlafaxine RR 8.8 (1.1-69) Sertraline RR 2.2 ( ) Paroxetine RR 2.2 ( ) Mirtazepine RR 1.6 ( ) Fluoxetine RR 1.5 ( ) Citalopram RR 1.4 ( ) T Hammad, T Laughren, J Racoosin 2006 SSRI s As Reducing Suicides In the U.S: every 1% increase in adolescent use of antidepressants correlates with a decrease of 0.23 suicides per 100,000 14% increase in U.S. youth suicides in 2004, the year SSRI usage started falling due to the black box warnings Olfson, M et al. Arch Gen Psych 2003 Gibbons R et al. Arch Gen Psych 2004 Gibbons RD, Brown CH, et al

29 How I Make Sense of SSRI Suicidality Agitation/anxiety is a SSRI side effect Common side effect, happens early on If make depressed or anxious person more anxious, logical to get some suicidal thoughts SSRI induced suicidal thoughts CAN happen, but they usually don t Why I check in with patient1-2 weeks after starting medicine Bridge et al, JAMA 2007 Where I see the role of SSRI in Child Depression Start with talk therapy alone if depression is not severe If not significantly better within 1-2 months, strongly consider medication trial If a moderate to severe depression, consider starting SSRI simultaneous with talk therapy 29

30 Medicating Major Depression Start low, go slow Change one medicine at a time Use a full dose range, wait 4-6 weeks before each increase Check in with patient ~2 weeks after starting to ensure no new suicidality Note original FDA follow up guideline of weekly visits for first month, biweekly 2 nd month etc. has been repealed SSRI Monitoring recommendation Frequency Suggestion Measure Height and weight Inquire about bleeding/bruising Inquire about activation symptoms Inquire about new suicidal thoughts Determine if treatment response At baseline and each follow-up, at least every 6 months (occasional weight gain problems) At least once after initiation of medication Screen for new irritability or agitation around week 2 & week 4-6 Screen for suicidality around week 2, week 4-6, and other visits such as after dose increases Repeat disorder specific rating scale(s) until remission is achieved. Increase at 4-6 week intervals if insufficient benefit. From Hilt R, Pediatric Annals,

31 SUGGESTED SSRI DOSAGES: DEPRESSION Medication Usual Adolescent Starting Dose Increase Increment (after 4-6 weeks) Max Dosage Youth RCT benefit Youth FDA Approval Fluoxetine 10mg/day 10-20mg 60mg Yes MDD Citalopram* 10mg/day 10-20mg 40mg Yes Escitalopram 5mg/day 5-10mg 20mg Yes MDD Sertraline* 25mg/day 25-50mg 200mg Yes --First line recommendation appears in bold --If a pre-adolescent, consider decrease these dosages by ~½ to 1/3 rd *Not FDA approved for depression What Other Meds Can Be Tried? If first SSRI fails, a second SSRI will work ~50% of the time Buproprion (Wellbutrin )* More agitation side effects A reasonable third choice if two SSRI s failed Reasonable if has ADHD too probably a lower rate of bipolar switching than SSRI s Mirtazapine (Remeron )* sedating, increases appetite Two negative child RCT s older adolescents may respond like adults TORDIA, 2008 *Not FDA approved for depression treatment in children 31

32 Other Agents Tricyclic Antidepressants* NOT recommended for depression in kids: studies show they are ineffective in addition to their toxicity risks Trazodone (Desyrel )* Might be useful as sleep aide, at up to 100mg Priapism risk a major concern Venlafaxine (Effexor )* side effects, withdrawal symptoms can be significant I d only recommend if an older adolescent with SSRI failure *Not FDA approved for depression treatment in children Other Resources Books adults may find helpful: The Childhood Depression Sourcebook (1998), by Jeffery Miller The Depressed Child: Overcoming Teen Depression (2001), by Mariam Kaufman Books kids may find helpful: Feeling Good: The New Mood Therapy (1999), by David Burns (for adolescents) Do it yourself CBT Taking Depression to School (2002), by Kathy Khalsa (for young children) Where s Your Smile, Crocodile? (2001) by Clair Freedman (for young children) Consumer guide to childhood depression from NAMI: 32

33 Questions? Contact info: