5/12/11. Disclosures. It Takes a Village : Creating alliances to manage teen depression

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1 It Takes a Village : Creating alliances to manage teen depression Shashank V. Joshi, MD, FAAP Lucile Packard Children s Hospital at Stanford svjoshi@stanford.edu Educational Objectives By session s end, participants should be able to: Describe current barriers to identification and support of students at risk for mental health disorders Define the supporting alliance concept, and list important ways the PCP can partner with schools and parents Develop a treatment plan for using pharmacotherapy in teen depression 2 Disclosures Research and Grant Support: -US Dept. of Education -Lucile Packard Foundation for Children s Health -Klingenstein Third Generation Foundation -Stanford University School of Education -Harman Endowment Fund 3 1

2 How are Clinicians to know when to worry? Normal Range Abnormal Range Developmental Variation Problem Disorder Primary therapeutic relationships Parents Teachers / School staff peers Student Doctors/ Therapists Adapted with permission from Feinstein, Fielding, Udvari-Solner, & Joshi: Amer Jnl of Psychotherapy, 63(4) 2009, Influences surrounding the patient media PCP peers Teachers & School staff MCO patient family prescriber therapist Adapted from Carli,

3 When Normal Stress Becomes Unmanageable " Primary Care Providers may be unsure of their roles " Students may find it hard to ask for help from the PCP or school staff " Peers may be unaware of signs and symptoms of depression " Parents may be afraid to ask their children about depression and self-harm 7 Buffer zones (Riera, Uncommon Sense for Parents of Teenagers 2004) Stress tolerance level Stress buffer zone Sedimented Stress via Traumatic Events: Divorce, Death of a loved one, Prolonged Illness, Financial Stress, Poverty, or other factors Girlfriend/ boyfriend rejection Exams College Graduation Apps Girlfriend/ Exams boyfriend rejection College Apps Graduation Other challenges " School personnel may experience parents and doctors as barriers to health, rather than as partners " Parents and Doctors may hold similar views of school personnel " Psychiatrists and other mental health providers are often difficult to reach 9 3

4 Treatment Alliance Too often a prescription signals the end of an interview rather than the start of an alliance Blackwell, 1973, p.252 Rationale and Theory for studying the Treatment Alliance All aspects of our work have psychological meaning to patients and families (Carli, 1999) The doctor-patient relationship as a drug-delivery system (Beitman, et al, 2003) The Psychotherapeutic Role of the Primary Care Provider, as described by Milton Senn, MD, Cornell University Pediatrician (1948) Better therapeutic alliances predict a more favorable medication response (Krupnick, et al, 1996) Outcome is poor if the relationship solely focuses on monitoring symptoms and side effects (Murphy, et al, 1995) The Psychotherapeutic Role of the Pediatrician Senn : Pediatrics 1948: Vol 2; commentary in Green: Pediatrics 1998: 102(1), More than any other professional, pediatricians [and other PCP s] are in a key position to prevent many psychological and developmental disorders through contributing to parents understanding of children, and of parent-child relationships p

5 The Psychotherapeutic Role of the Pediatrician Senn : Pediatrics 1948: Vol 2; commentary in Green: Pediatrics 1998: 102(1), Skill in interviewing parents and children is the single most useful tool that providers can master in relation to the psychosocial aspects of pediatrics p Rationale and Theory for importance of this approach Treatment Alliance in psychopharmacology Also referred to as the Therapeutic Alliance The collaborative bond between prescriber and patient And parent! Recognized across paradigms as a cornerstone of effective treatment The offer of treatment as a non-neutral act The meaning of the medication itself, and on the self Fears of change in baseline personality, onset of a zombie effect, or a loss of joie de vivre Important to discuss these as potential, (but unacceptable) side effects Others worry that self perceptions will be altered I love my symptoms, Doc, they make me myself! (Pruett & Martin, 2003; p.418) Backhanded compliments; Using clinic visits and phone calls with teachers to educate about this 5

6 The meaning of the medication itself, and on the self Teens developmental tasks May feel changed as a person May carry on relationship with the pill itself Actual role for medication? All too often it is unclear whether a medication heals directly or mainly removes obstacles to selfhealing Schowalter, 1989; p.683 The act of writing and giving the prescription Best saved until the very end of a session After adequate time has been devoted to questions from both patient and parent Tailor explanation Developmental age of child Developmental stage of parent Most middle- and older teens: Comments and prescription directed primarily to them Other option Who should I give this to? Psychologic analgesics (Havens, 2000) 1) Protecting self-esteem: It is safe to assume that the patient s self-esteem has been potentially affected by having to come to your office, and that the parent is feeling sufficiently bad for having caused the illness, through bad parenting, poor gene contribution, or both. Be mindful of how you help the patient and parent hold it together in your presence. 2) Emoting a measure of understanding and acceptance: When this is successful, you ve not only grasped the patient s problem intellectually, but you ve really conveyed an understanding of the patient and family s predicament from their point of view. 6

7 Psychologic analgesics (Havens, 2000) 3) Providing a sense of future: Many families come to us having experienced much frustration and failure at finding usable solutions, and have lost hope. Have discussions about what they d like to achieve in treatment, and acknowledge their hopelessness while still offering reminders of the potential for change, It may seem hopeless to you for now. SSRI and Newer Antidepressants Brand NameGeneric Name Approved Age Anafranil clomipramine **10 and older (for OCD) Celexa citalopram 18 and older Effexor venlafaxine 18 and older Lexapro escitalopram **12 and older (for depression) Luvox fluvoxamine **8 and older (for OCD) Paxil paroxetine 18 and older Prozac fluoxetine **8 and older (for depression) Remeron mirtazapine 18 and older Serzone nefazodone 18 and older Sinequan doxepin 18 and older Tofranil imipramine **6 and older (for bedwetting) Wellbutrin bupropion 18 and older Zoloft sertraline **6 and older (for OCD) Major Depression - Treatment Strategies Refer for Psychotherapy immediately, or provide active support in your clinic Select drug based on effectiveness, side effects, ease of ingestion, other medical conditions, drug interactions Consider family history of response Establish target symptoms and monitor closely May use CDI (Kovacs), other questionnaires Empower placebo effect 7

8 Major Depression - Treatment Strategies Lexapro (escitalopram) and Prozac (fluoxetine) are FDA-indicated for pediatric depression Both are well-tolerated, but must be monitored closely Lexapro: start with mg daily (max daily dose 20 mg) Prozac: 5-10 mg daily (max daily dose 60 mg) -other meds do have empiric support, though no FDA indication yet (citalopram, sertraline) SSRIs - Common Adverse Effects GI upset, headache Drug-drug interactions more an issue for Prozac (fluoxetine), not for Lexapro (escitalopram) SSRIs Less Common Adverse Effects Increased anxiety, agitation Suicidal thinking ( jumping out of my skin ) Ht. velocity slowing 8

9 Monitoring treatment response After beginning treatment with pharmacotherapy, monitor especially carefully for 1 st 3 months: Weekly visits for 1 st month Bi-weekly during 2 nd month Monthly visits thereafter FDA link MG_template.pdf Long term treatment of Children with medications For children who improve markedly, consider recommending a medicationfree trial. This trial is ideal for the 1st low-stress period after 1 year of continual medication treatment. Medication treatment should be reinitiated in children who exhibit signs of relapse. Research-based practical suggestions for promoting adherence TalK Does Foster Superior Patient Care Mnemonic for important factors Therapeutic Alliance with provider Knowledge and education re: medicine Dosing Frequency Scheduling of doses (link with context) Palatability (adults more than kids) Cost (accessibility) Source: Hack and Chow: J Child & Adol Psychopharmacology, 11(1)

10 Primary therapeutic relationships Parents Teachers / School staff peers Student Doctors/ Therapists Adapted with permission from Feinstein, Fielding, Udvari-Solner, & Joshi: Amer Jnl of Psychotherapy, 63(4) 2009,