Depression & Anxiety in Adolescents

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1 Depression & Anxiety in Adolescents Objectives 1) Review diagnosis of anxiety and depression in adolescents 2) Provide overview of evidence-based treatment options 3) Increase provider comfort level with medication management»kristin M. Rager, MD, MPH, FAAP, FSAHM What is normal? Normal does not mean always happy, always easy Teens have a lot going on, physical, social, and cognitive changes, which can make their behaviors seem abnormal to adults at times Normal does not mean significantly impaired function this is out of the realm Depression Diagnosis 5 of the following during same 2 week period and a significant change from baseline 1. Depressed or irritable mood 2. Decreased interest or lack of enjoyment 3. Decreased concentration or indecision 4. Insomnia or hypersomnia Depression Diagnosis SIGECAPS or DIGSPACES 5. Change of appetite or change of weight 6. Excessive fatigue 7. Feelings of worthlessness or excessive guilt 8. Recurrent thoughts of death or suicidal ideation 9. Psychomotor agitation or retardation Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicidality Depressed mood Interest Guilt Sleep Psychomotor Appetite Concentration Energy Suicidality 1

Anxiety Diagnosis Excessive worry more days than not for at least 6 months about a number of events and they find it difficult to control the worry 3 or more of the

distress or impairment PHQ Scoring GAD 7 Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe

2 Anxiety Diagnosis Excessive worry more days than not for at least 6 months about a number of events and they find it difficult to control the worry 3 or more of the following symptoms: Restlessness or feeling keyed up or on edge easily fatigued difficulty concentrating, irritability muscle tension sleep disturbance Causes significant distress or impairment PHQ Scoring GAD 7 Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression Moderate depression Moderately severe depression Severe depression GAD 7 Scoring» 5-9 mild anxiety» moderate anxiety» 15 and up severe anxiety First and most important step. Identifying those teens who need help 2

alone first in mildly affected Child and Adolescent Anxiety Multimodal Study (CAMS) SSRI and CBT led to signif clinical improvement in 80% Treatment for Adolescents with Depression (TADS) study SSRI

3 Treatment OPTIONS Psychotherapy Should be recommended to ALL patients with depression or anxiety May be through multiple different venues! Medication Psychotherapy PLUS Medication Selective serotonin reuptake inhibitors (SSRI s) Medication should be recommended to all patients with moderate to severe depression May consider therapy alone first in mildly affected Child and Adolescent Anxiety Multimodal Study (CAMS) SSRI and CBT led to signif clinical improvement in 80% Treatment for Adolescents with Depression (TADS) study SSRI and CBT led to significant clinical improvement in 71% Psychotherapy Medications Cognitive behavioral therapy (CBT) - helps patient recognize and change negative patterns of thinking that may contribute to depression Significant evidence for its efficacy SSRI s Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Viibryd (Vilazodone) 3

4 Fluoxetine (Prozac) Fluoxetine Dosing FDA Indications- MDD 8 yo and above and OCD 7 yo and above, BN and PD 18 and above Longest ½ life (1-3 days after a single dose) May help prevent relapse as well (40% at 2 years without treatment) Starting dose 10 mg daily Target dose 20 mg daily Maximum dose 60 mg daily Sertraline (Zoloft) Paroxetine (Paxil) FDA Indications -MDD, PD, PTSD, SAD, PMDD 18 and over, OCD 6 yo and above Dosing Starting dose 25 mg daily Target dose 50 mg daily Maximum dose 200 mg daily Several studies have found no indication of efficacy against depression in adolescents FDA 2003 strongly advises against its use in patients under 18 years old There is currently no evidence that Paxil is effective in children or adolescents with MDD Citalopram (Celexa) Escitalopram (Lexapro) FDA Indication - MDD 18 and over Adult Starting dose 20 mg daily Target dose 40 mg daily Maximum dose 40 mg daily FDA Indication - MDD 12 yo and above and GAD 18 and above Starting dose 10 mg daily Target dose 10 mg daily Maximum dose 20 mg daily 4

5 Vilazodone (Viibryd) Liquid Formulations No FDA Pediatric Indication - MDD 18 and above Starting dose 10 mg daily Target dose 20 mg daily Maximum dose 40 mg daily» Fluoxetine 20mg/5 ml» Sertraline 20mg/1 ml» Escitalopram 5mg/5ml» Citalopram 10/5ml SSRI tidbits Side effects of SSRI s Start low, go slow (increase from starting dose to target dose after 1-2 weeks) Improvement is not instantaneous Symptoms begin to improve 2-4 weeks after target dose is reached 30 40% of teens do not respond to the initial treatment at all Generally well tolerated with minimal or no side effects Generally increase with increase in dose Usually subside in 1-2 weeks Most commonly headache, abdominal pain, nausea, diarrhea, sleep changes, jitteriness Side effects of SSRI s Why the black box? Changes in sexual functioning (decreased libido, delayed ejaculation, anorgasmia) Can induce mania or hypomania in those with bipolar disorder Suicidality??? 23 trials involving more than 4300 children and adolescents NO suicides in any of these studies Information was looked at 2 ways 5

6 Black Box Warning Suicidality and the Black Box Warnings Did not prohibit use of the medications in youth, but called on physicians and parents to closely monitor children and adolescents who are taking antidepressants for a worsening in symptoms of depression or unusual changes in behavior. As of May 2007 includes young adults years October 15, 2004 FDA directed pharmaceutical companies to label all antidepressants with the warning that they "..increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) or other psychiatric disorders Black Box Warning Adverse Event Reports States that the increased risk of suicidal thinking and/or behavior in a small proportion of children and adolescents is most likely to occur during the early phases of treatment Reports made by the investigator if the patient spontaneously reports a side effect (suicidal thoughts) 4% in patients on meds 2% in those on placebo When patients were asked about suicidal thoughts and behaviors at each visit Existing suicidality was not increased nor was new suicidality produced by meds Suicidal thoughts were decreased SO what happened in response In the year following the Black Box, in those less than 17 years old Overall prescribing of antidepressants decreased by 10% New prescriptions decreased by 20% 6

7 In addition What to do instead of not prescribing - Close Monitoring The overall rate of suicide in the year age range has declined by 25% over the past decade This decade has been associated with a dramatic increase in the prescription rates of SSRI s If meds increased suicidal behaviors, you would expect an increase in the suicide rate as prescriptions went up Weekly for the first 4 weeks Every other week for the next 4 weeks After 12 weeks Then as clinically indicated SSS symptoms, sides, suicidality How long to stay on meds? What if first med doesn t work? I feel better now, so I stopped my Prozac Should continue for 9-12 months after the patient is back to normal Relapse is significantly higher if meds are stopped sooner Should taper dose down to prevent discontinuation syndrome decrease the dose by 25 to 50% weekly» 6-12 weeks at therapeutic dose» try 2nd ssri and/or ADD THERAPY» after 6-12 weeks at therapeutic dose» try other med and/or ADD THERAPY Other Meds» Bupropion (Welbutrin)» aminoketone for MDD, SAD 18 and over» Venlafaxine (Effexor)» SNRI for MDD, GAD, SAD, PD 18 and over» Desvenlafaxine (Pristiq)» SNRI for MDD 18 and over» Duloxetine (Cymbalta)» SNRI for MDD, GAD, Pain, FM 18 and over Other other meds» Buspirone (Buspar)» Non benzo anxiolytic» Hydroxyzine» Antihistamine» Benzos» in general, just no 7

8 Conclusions Conclusions Depression and anxiety are national public health problems for children and adolescents Both are serious medical illness and may be potentially lethal because of the risk of suicide. When recognized and correctly diagnosed, depression and anxiety can be treated successfully A combination of therapeutic approaches should be utilized, preferably medication AND psychotherapy individualized to the needs of a teen and his or her family Thanks! Questions» rager@ragermd.com 8

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