Impact of Psychotropics in School
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- Thomasina Leonard
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1 Impact of Psychotropics in School H O W T O C O O R D I N A T E C A R E A C R O S S S E T T I N G S W I L L I A M P U G A, M D C H I L D A N D A D O L E S C E N T P S Y C H I A T R I S T
2
3 Age of onset Anxiety Disorders Specific to childhood Separation anxiety School phobia Selective mutism OCD ADHD Autism Spectrum Tourette s Major Depression Female: adolescence-childbirth-menopause Major mental illness: Bipolar: half start before 25 yo Schizophrenia: yo (ave 18 in males, 25 in women)
4 Mood Disorders
5
6
7 BIO-PSYCHO-SOCIAL Bio- Psycho- Social-
8 Psychiatric Diagnosis Axis I Psychiatric Axis II DD PD Organic Substance Abuse
9 Psychiatry 101
10 Oh, Homey!
11 Division of labor
12 Neuron
13 Synapse
14
15 Monoamine Theory Limbic system Adrenalin Noradrenalin Serotonin (anxiety, sleep, eating) Dopamine (psychosis, concentration) GABA (inhibitory) Glutamate (activating) 90% inhibitory
16 The Triune Brain: how therapy works
17 Prodromal Symptoms
18 Under 7 y/o everything looks like ADHD ADHD LD Bipolar Psychosis Anxiety 7 y/o?
19 Mood disorders
20 Mood Disorders
21 Bipolar vs Unipolar Bipolar: Chemical imbalance No ceiling, no floor Unipolar depression: chemical + receptor/neuro anatomy Post-mortem brain biopsy results At least 2 weeks to change receptors
22 Classic Clinical Symptoms
23 Masked depression
24 Pieces of the Bipolar Puzzle Family history Affective storms Sleep!! Psychosis Vegetative symptoms of depression prepubertal Atypical depression: sleep and appetite Hard to treat ADHD Adverse reactions to other Rx s Stimulants: psychosis/ speed Strattera: rage Antidepressants: rage
25 Genetics of Bipolar General risk: 3-8% One parent: 15-25% Two parents: 60% Poly-genetic Monozygotic twins: 60% concordance
26 Childhood Bipolar Factoid Incidence in Adults: 1-3% Incidence in Children > Adults
27 Fad? Diagnosis of Bipolar may be old school very soon DSM 5: Disruptive Mood Dysregulation Disorder
28 MEDS
29 Antidepressants MAOI S Tricyclic antidepressants SSRI s Prozac
30 How do anti-depressant work? Fouling up the clean-up system MAO Uptake I pump
31 Meds making thing worse? Undiscovered bipolar? Antidepressants, stimulants Increased aggression Psychosis More hyper
32 Mood stabilizers Lithium Anti-seizure Depakote Tegretol/Trileptal Topamx/Zonegran Anti-Psychotics Risperdal zyprexa Seroquel Abilify Geodon Latuda
33 Atypical risks Elevated cholesterol Insulin resistance/risk of diabetes Weight gain Sedation
34 ADHD Triad: hyperactivity impulsivity inattention
35 8% of population M>F 9:1 Inattentive 4:1
36 ADHD History: Dr Charles Bradley, 1937 Meningitis epidemic Benzadrine Minimal brain dysfunction Current view Developmental delay? MRI: 3-5 yr lag in prefontal cortex development
37 Gray matter maturation
38 ADHD causes Genetics: Developmental? Hard drive damage: Birth (or later?) trauma physical: O2 deprivation toxic: alcohol, drugs, tobacco, Pb infectious-prenatal or peri-natal
39 Symptoms ADHD over a lifespan Childhood Puberty Adulthood
40 ADHD lifecycle 70% of patients will grow out of most ADHD symptoms 25% of patients will require meds as an adult
41 Actigraphy: Bipolar vs ADHD
42 Bipolar vs. ADHD Bipolar Awakens in the night Grandiose Irritable mood- affectice storms ADHD Initial insomnia Demoralized Poor frustration tolerance Racing thoughts Pressured speech Psychosis Family hx of bipolar
43 ADHD Meds
44 Stimulants Rx s that help: Increase dopamine Increase noradrenalin Histamine? Ritalin vs Adderall = Pepsi vs Coke Timing is everything
45 Timing is everything
46 Anxiety
47 Anxiety disorders Eu -anxiety Adjustment disorder Panic Disorder PTSD GAD Social OCD Separation anxiety Mash-up
48 Panic Disorder Hereditary F>M, 2:1 Locus ceruleus (Noradrenalin) over active 40% of school phobia kids will have panic disorder in adulthood
49 PTSD Rx: SSRI Clonidine/Tenex: noradrenalin Topamax Minipress (prazosin): NE Males 1-3mg Females higher (-45?)
50 Separation anxiety disorder Separation anxiety Normal 8 months-15 months (peak months?) Disorder 4% children, 7% adults Future Increase likelihood of ADHD, bipolar, panic disorder
51
52 OCD Caudate nucleus: very overactive Genetics: incomplete penetrence PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections)
53 OCD RX Tx: High doses of SSRI s Prozac mg Inositol 3000mg + Anafranil Adol 150mg Level, EKG Neurontin? Zofran 1-4 mg tid
54 RX s Anti-depressants: mainstays of treatment Ssri s Snri s Maoi s Remeron Benzodiazepines (GABA 1): addictive Short acting: ativan, xanax Longer acting: Klonopin, valium, librium GABA 2 Neurontin/lyrica Buspar Alpha-Agonists Clonidine Tenex Zofran
55 Anxiety Meds
56
57
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