Wisconsin Alliance of Child Psychiatry & Pediatrics (WACPP) Lunch & Learn Webinar: Mood Disorders December 9th, 2014

Transcription

1 Wisconsin Alliance of Child Psychiatry & Pediatrics (WACPP) Lunch & Learn Webinar: Mood Disorders December 9th, 2014

2 Financial Disclosure In accordance with the ACCME standard for Commercial Support Number 6, all in control of content disclosed any relevant financial relationships. The following in control of content had no relevant financial relationships to disclose. Name: Todd Eisenberg, MD Peggy Scallon, MD Ryan Byrne, MD Rosa Kim, MD Joseph O Grady, MD James Meyer, MD Kia LaBracke Kristina Manke Role in Meeting: Presenter / Planning Committee Presenter / Planning Committee Planning Committee Planning Committee Planning Committee Planning Committee Planning Committee Planning Committee

3 Statements Accreditation: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the Medical College of Wisconsin and Wisconsin Alliance of Child Psychiatry & Pediatrics. The Medical College of Wisconsin is accredited by the ACCME to provide continuing medical education for physicians. AMA Credit Designation: The Medical College of Wisconsin designates this Live Activity for a maximum of 1 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity.

4 WACPP Mental Health Webinar Today s webinar is an educational activity, not a specific case consultation activity. For a specific case consultation need, we would refer you to a child and adolescent psychiatrist for a clinical consultation

5 Acknowledgements The Wisconsin Alliance of Child Psychiatry & Pediatrics (WACPP), established in 2009, is a collaboration between the Wisconsin Council of Child and Adolescent Psychiatry (WCCAP) and the Wisconsin Chapter of AAP (WIAAP Foundation). These WACPP Mental Health Webinars are funded in part by the Landis Endowment of the Wisconsin Medical Society Foundation. This program was also made possible by an a grant from the Wisconsin Statewide Medical Home Initiative.

6 Psychiatry Course Director and Facilitator: Joseph O Grady Jr. M.D. FAAP Associate Professor of Clinical Psychiatry Medical College of Wisconsin jogrady@mcw.edu Medical Director Phoenix Care Systems Inc Ryan Byrne, MD Assistant Professor of Psychiatry and Behavioral Medicine Medical College of Wisconsin rbyrne@mcw.edu Rosa Kim, MD Assistant Professor of Psychiatry and Behavioral Medicine, Division of Child and Adolescent Psychiatry Medical College of Wisconsin rkim@mcw.edu

7 Pediatric Course Director and Facilitator: James Meyer, M.D. FAAP Adolescent Medicine specialist Marshfield Clinic President Wisconsin Chapter, American Academy of Pediatrics Foundation (WIAAP)

8 Presenters Peggy Scallon, MD Professor, Child & Adolescent Psychiatry University of Wisconsin Todd L. Eisenberg, MD Child & Adolescent Psychiatrist Rogers Memorial Hospital, Affiliated Clinical Services, Psychiatric and Psychotherapy Clinic, and Wisconsin Medical Group

9 Presentation Goals Participants will acquire practical knowledge in the assessment within primary care of children and adolescents regarding mood disorders. Participants will acquire practical knowledge in the treatment within primary care of children and adolescents regarding mood disorders. Participants will acquire practical knowledge with assessing children and adolescents with psychiatric disorders who require a referral for a higher level of care regarding mood disorders.

10 Mood Disorders: Outline 1. Case presentation, Part 1 2. Assessment and Treatment of Childhood and Adolescent Depression In Primary Care Settings 3. Case presentation, Part 2 4. Question & Answer

11 WACPP Mood Disorders CASE STUDY James A. Meyer, MD Adolescent Medicine, Marshfield Clinic 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.

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

13 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)

14 Case: PMHx 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).

15 Case: Laura FHx 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 anxiety.

16 Case: Laura Dramatic, sudden but episodic mood changes: extremely 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.

17 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 excess caffeine or suspected alcohol or drug use.

18 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.

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

20 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?

21 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

22 Case: Laura Well groomed but dressing older than her age. Boisterous and uninhibited. Argues continuously with her mom during the visit. Normal exam. 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.

23 Assessment and Treatment of Childhood and Adolescent Depression In Primary Care Settings Peggy Scallon MD Professor, Child & Adolescent Psychiatry University of Wisconsin Todd L. Eisenberg, MD Child & Adolescent Psychiatrist Rogers Memorial Hospital, Affiliated Clinical Services, Psychiatric and Psychotherapy Clinic, and Wisconsin Medical Group December 9, 2014

24 Clinical assessment flowchart Zuckerbrot R A et al. Pediatrics 2007;120:e1299-e1312 Cheung A H et al. Pediatrics 2007;120:e1313-e by American Academy of Pediatrics

25 Step 1: Early Identification Depression risk factors Patient history of depression, bipolar disorder, or suicidal behavior Family history of depression, bipolar disorder, or suicidal behavior Patient exposure to negative life events, loss, trauma, maltreatment Shy temperament General medical conditions (epilepsy, cerebral palsy, diabetes) Youth presents to clinic or urgent care for health maintenance visit Early Identification: Systematically identify high-risk youth Exposure to medications (anticonvulsants, OCP)

26 Step 2: Assessment Patient Health Questionnaire 9 (PHQ-9) PHQ-9 Modified for Teens Center Epidemiologic Studies Depression Scale (CES-D) Columbia DISC Depression Scale Kutcher Adolescent Depression Scale (KADS) Mood and Feeling Scale (MFQ) Mood and Feeling Questionnaire Parent (MFQP) Assessment A. Assess with systematic depression assessment tool B. C.

27 Reference 10

28 Step 2: Assessment (continued) Clinical interview of patient and family Assessment Symptoms SIG E CAPS Other mental illnesses Patient functioning Psychosocial adversity Physical health Family psychiatric history A. B. Interview patient and parent to assess for depression and other psychiatric disorders with DSM-IV TR or ICD- 10 criteria C.

29 Step 2: Assessment (continued) Clinical interview of patient and family - continued Assessment Physical conditions that may present with depression Environmental structure, support History of mental illness and developmental problems A. B. Interview patient and parent to assess for depression and other psychiatric disorders with DSM-IV TR or ICD- 10 criteria C.

30 Sample Questions to elicit self-harm and suicidal ideation Do you ever wish you weren t alive? Have things ever gotten so bad that you thought about harming yourself? Have you ever tried to harm yourself? Are you concerned that you might harm yourself now? A. B. Assessment C. Assess for safety/suicide risk

31 Step 3: Evaluation of the Presumably Depressed Patient Assessment A, B, and C Positive for depression (see next step) Evaluation negative for depression but positive for other mental health concerns: Treat or refer for treatment. Monitor for depression at every following appointment If psychotic or suicidal: Refer to Crisis or Emergency Services

32 Step 4a: Diagnostic clarification of the depressed patient Major Depressive Disorder Assessment Disruptive Mood Dysregulation Disorder Dysthymic disorder Mood disorder due to a general medical condition Adjustment disorder other MH A, B, and C Depressed patient Psychotic or suicidal

33 Step 4b: Initial management of the depressed patient who is not psychotic or suicidal Patient & family education on depression Assessment Education on mood hygiene Risks, benefits, and alternative treatments Develop treatment plan other MH A, B, and C Depressed patient Psychotic or suicidal Develop safety plan

34 2007 by American Academy of Pediatrics Cheung A H et al. Pediatrics 2007;120:e1313-e1326

35 References: American Academy of Child nd Adolescent Psychiatry (2007), Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. JAACAP 46(11): Bridge, JA, et al. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment. JAMA. April 2007;(297)15: Dulcan, M, et al. Concise Guide to Child and Adolescent Psychiatry. Arlington, VA American Psychiatric Publishing, Inc Emslie, GJ, et al. A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Arch Gen Psychiatry. 1997;54: Emslie, GJ, et al. Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled, randomized clinical trial. J Am Acad Child Adolesc Psychiatry. 2002;41:

36 References (cont d): Jacquez-Dean, S. Depression and Anxiety Disorders in Children and Adolescents, Presentation, September es.pdf Cheung A H et al. Guidelines Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and Ongoing Management. Pediatrics 2007;120:e1313-e1326 Zuckerbrot R A et al. Guidelines Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics 2007;120:e1299-e1312

37 References (cont d): Moisio, S. Depression in Pediatric Practice: Overview of Diagnosis and Treatment Options, Presentation, MCW, April 28, Scheffer, R. Depression & Anxiety, Presentation, Door Co., WI August English.PDF Protocol.pdf 0Form%20of%20AAP.pdf

38 Peggy Scallon, M.D

39 Treatment of Mild, Moderate, and Severe Depression Psychotherapy is usually sufficient for mild depression Moderate to Severe Depression require combination medications plus psychotherapy (TADS Study results)

40 Treatment of Resistant Depression in Adolescents Study (TORDIA) Adolescents aged 12 to 18 with treatment resistant depression (had one previous SSRI trial) Switching to either another SSRI or venlafaxine improved response Adding CBT improved response Venlafaxine had more side effects

41 FDA Black Box Warning for antidepressants In 2004, the FDA issued a black box warning on all antidepressants in children and adolescents. The warning was based upon a review of studies of youth treated with antidepressants. 4% of those on SSRIs spontaneously reported suicidal thoughts compared to 2% on placebo

42 Consensus regarding Antidepressants and SI We should use antidepressants in children and adolescents with depression. Children and adolescents placed on antidepressants should be closely monitored during the first few months of treatment and any time a dose is changed. Parents and caregivers should be made aware of the warning and for signs and symptoms that are concerning Agitation Suicidal thoughts Behavioral disinhibition

43 Resources about the FDA warning and-caregivers.shtml

44 Medications to treat Depression in Youth SSRIs Venlafaxine Duloxetine Mirtazapine Buproprion

45 Fluoxetine Generally the most studied SSRI in children and adolescents Of the SSRIs, Fluoxetine showed the most difference when compared to placebo. Typical dose is mg Side Effects: Behavioral activation Difficulty with sleep Diarrhea or other stomach difficulties Sexual Side Effects Special Notes: Fluoxetine FDA approved for depression in children over 8 Fluoxetine has the longest half life of the SSRIs, which makes it a good choice for teens, who may have poor compliance with medications

46 Other SSRI Medications Sertraline mg Citalopram mg Escitalopram FDA approval for depression ages 12 and older mg Fluvoxamine mg- usually used for OCD

47 Paroxetine DO NOT USE IN CHILDREN OR ADOLESCENTS Increased rate of suicidal ideation compared to the other SSRI antidepressants!

48 Venlafaxine SNRI TORDIA shows efficacy in adolescents with depression Typical Dose Adolescents: up to 225mg daily Side Effects Hypertension, sweating and flu-like withdrawal profile

49 Duloxetine SNRI Generally avoid use in children (little evidence) Adolescents: 40-60mg daily Side Effects sleepiness or insomnia constipation or diarrhea

50 Mirtazapine Alpha antagonist Typical Dose is 15mg to 30mg with max dose of 60 mg Side Effects Sedation Weight Gain Constipation

51 Buproprion Dopamine and norepinephrine reuptake inhibitor Typical dose: 150mg- 450mg daily Best to use the once-daily XL formulation Side effects Activation Anxiety seizures Also helpful for ADHD Contraindicated in those with eating disorders or others with risk of seizures

52 Guideline for the use of medications in depression Start low and go slow! All antidepressants require 4-6 weeks for an adequate trial. Be aware of the risk of behavioral dis-inhibition.

53 Guidelines for Ongoing Treatment of Depression Continue medication for 8-12 months after resolution of depressive symptoms Once out of treatment, children and adolescents with depression should be monitored for at least 1-2 years for ongoing depression, depending on history of relapse. Greatest risk of relapse is in the first 3 months after discontinuation of medications

54 Psychotherapy Cognitive Behavioral Therapy Dialectical Behavioral Therapy Interpersonal Therapy Family-Based Therapy Supportive Psychotherapy

55 Take home points Depressive disorders are common in children and adolescents. Screen for suicidality and safety, even as depressive symptoms are improving. Initial treatment of mild depression can be with psychotherapy alone Treatment of moderate or severe depression should include meds and psychotherapy. Combination therapy shows earlier improvement and protects against suicidality than meds alone.

56 References American Academy of Child and Adolescent Psychiatry (2007) Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Cheung, A., Zuckerbrot, R., Jensen, P., Ghalib, K. Laraque, D. Stein, R., and the GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC):II. Treatment and Ongoing Management. Pediatrics, 2007;120:e1313-e1326. Kennard, Betsy, et. Al. Remission and Residual Symptoms after short term treatment of Adolescents in the TADS. J. Am. Acad. Child Adoles. Psychiatry, 2006; 45 (12): Sharp, Lisa PHD and Martin S Lipsky. Screening for Depression Across the Lifespan: A review of Measures for Use in Primary Care Settings. American Family Physician (6)

57 References Treatment for Adolescents with Depression Study Team (2004) Fluoxetine, Cognitive Behavioral Therapy, and their combination for adolescents with depression. JAMA, Vol 292, No Watanabe N, Hunot V, Omori IM, et al (2007), Psychotherapy for depression among children and adolescents: a systematic review. Acta Psychiatrica Scandinavica 116: Zuckerbrot, R., Cheung, A., Jensen, P., Stein, R., Laraque, D. and the GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC):I. Identification, Assessment and Initial Management. Pediatrics, 2007; 120:e1299-e

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

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

60 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.

61 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 anxiety/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 anxiety somatic and conduct Increased externalizing T score of 75 T score median 50, Standard deviation of 10. T score of 67 top 5%.

62 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 six years old, and symptoms must begin before age ten. Symptoms must be present for at least one year.

63 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, exercise. 2) Medication Phone consultation with Child Psychiatrist. Started guanfacine 0.5mg bid

64 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.

65 Case: Laura Follow Up Follow up- 1) Phone update in 1 week to screen for: - basic side effects: excess 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.

66 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 (atomoxetine) for affective and ADHD symptoms. Started at 10mg titrated up to 40mg. Appears to be doing well on combination.

67 Questions

68 Contact Information Facilitators: Dr. James Meyer Marshfield Clinic, Dr. Joseph O Grady Medical College of Wisconsin, jogrady@mcw.edu Presenters: Ryan Byrne, MD Medical College of Wisconsin rbyrne@mcw.edu Rosa Kim, MD Medical College of Wisconsin, rkim@mcw.edu