Child & Adolescent Psychiatry (a brief overview)

Transcription

1 Child & Adolescent Psychiatry (a brief overview) Lance Feldman, MD, FAPA, MBA, BSN Vice Chair Clinical Affairs, Department of Psychiatry Affiliate Clinical Assistant Professor, University of South Carolina School of Medicine Greenville Diplomate, American Board of Psychiatry & Neurology, Psychiatry Diplomate, American Board of Psychiatry & Neurology, Child & Adolescent Psychiatry Diplomate, American Board of Addiction Medicine

2 Disclosures None (We may, however, be discussing some possible off label medication uses, especially in the pediatric population.)

3 Outline Depression Anxiety Attention Deficit Hyperactivity Disorder (ADHD) 3

4 Prescribing Pearls Chlorpromazine (Thorazine) FDA approved ages >6 months for schizophrenia / psychosis CDC the long term effects of ADHD medicine on young children are not known FDA Pregnancy Category C Methylphenidate has been shown to have teratogenic effects in rabbits when given in doses of 200mg/kg/day 4

5 Before Psychopharm Modifiable Risk Factors Sleep Exercise Nutrition Family* Friends* Employer / Place of Employment* 5

6 Depression 6

7 Making the Diagnosis Screening Tools PHQ Clinical Interview Collateral Information (the Fs ) Criteria Treatment 7

8 Depression Criteria Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) Insomnia or hypersomnia nearly every day. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). Fatigue or loss of energy nearly every day. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. 8

9 Neurotransmitters Serotonin Norepinephrine Dopamine 9

10 10

11 FDA Approved Mood / OCD Medications

12 Other Medications Paroxetine (Paxil) Citalopram (Celexa) Venlafaxine (Effexor) Duloxetine (Cymbalta) Mirtazapine (Remeron) Bupropion (Wellbutrin) Trazodone (Desyrel) 12

13 TADS Trial Treatment for Adolescents with Depression Study (TADS) 439 patients, y/o, MDD, 13 clinics 12 weeks of: fluoxetine alone, CBT alone, fluoxetine + CBT, placebo

14 TADS

15 Anxiety 15

16 Making the Diagnosis Screening Tools SCARED Clinical Interview Family History Criteria Treatment 16

17 Generalized Anxiety Disorder Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). The individual finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children. Restlessness or feeling keyed up or on edge. Being easily fatigued. Difficulty concentrating or mind going blank. Irritability. Muscle tension. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). 17

18 Anxiolytics SSRIs Benzodiazepines (Lorazepam, Clonazepam, Alprazolam) Buspirone (Buspar) Hydroxyzine (Vistaril) Cognitive Behavioral Therapy (CBT)

19 CAMS Trial Child/Adolescent Anxiety Multimodal Study (CAMS) 488 participants with DSM-IV separation, generalized, or social anxiety disorder randomized to 12 weeks of cognitive-behavioral therapy (CBT), sertraline (SRT), CBT+SRT (COMB), or medication management/pill placebo (PBO). Responders attended 6 monthly booster sessions in their assigned treatment arm; youth in COMB and SRT continued on their medication throughout this period. Efficacy of COMB, SRT, and CBT (n = 412) was assessed at 24 and 36 weeks postrandomization. Youth randomized to PBO (n = 76) were offered active CAMS treatment if nonresponsive at week 12 or over 19

20 CAMS Results 20

21 ADHD 21

22 Making the Diagnosis Screening Tools Vanderbilts, Connors, CBCL, ADHD Rating Scale IV Clinical Interview Family History Criteria Treatment 22

23 ADHD Medications Stimulants (Methylphenidate, Amphetamine) Non-Stimulants Alpha-2 agonists Atomoxetine Other 23

24 Stimulants in Normals Improved Cognition Improved Memory working & episodic Improved Task saliency 24

25 Methylphenidate Mechanism Dopamine and Norepinephrine reuptake inhibitor (transporter) Increase concentrations of DA and NE in the synaptic cleft Activation of Prefrontal Cortex 25

26 Stimulants Methylphenidate Products: IR: Ritalin, Focalin, Methylin ER: Ritalin LA, Ritalin SR, Concerta, Focalin XR, Methylin ER, Metadate CD, Metadate ER, Aptensio XR QuilliChew ER chewable Quillivant XR liquid suspension Daytrana - patch 26

27 Long Acting Products Concerta 22% / 78% Metadate CD 30% / 70% Ritalin LA 50% / 50% Focalin 27

28 Amphetamine Mechanism Reuptake Inhibitor of DA & NE Release of DA & NE Reduce firing rate Reverse flow of monoamines 28

29 Stimulants Amphetamines: Short Acting: Adderall, Dexedrine, Procentra Long Acting: Adderall XR, Vyvanse, Dyanavel XR 29

30 Adderall (Dextroamphetamine) 25% dextroamphetamine sulfate 25% amphetamine sulfate 25% dextroamphetamine saccharate 25% amphetamine aspartate monohydrate 30

31 Non-Stimulants: SNRI Atomoxetine (Strattera) Selective norepinephrine reuptake inhibitor 10, 18, 25, 40, 60, 80, 100mg doses 4-8 weeks at least Up to 60% efficacy No abuse potential No withdrawal effects Black Box: suicidal ideation $621.4 million (Eli Lilly, 2.7%) 31

32 Non-Stimulants: Alpha 2s Guanfacine Guanfacine ER (Intuniv) Guanfacine (Tenex) Clonidine Clonidine ER (Kapvay) Clonidine (Catapres) 32

33 Alpha 2 Agonist Mechanism Modulate noradrenergic tone in PFC Extend / Enhance stimulant therapy Monotherapy XR prodcuts 33

34 Other Treatments for ADHD Bupropion Omega 3 FAs Diet / Nutrition Therapy 34

35 Clinical Considerations Goal of treatment (Is it realistic?) Dosing guidelines Taking medications as prescribed OTC supplements Therapy (CBT, DBT, etc) 35

36 Cognitive Behavioral Therapy 36

37 37

38 Questions? 38

39 Disruptive Mood Dysregulation Disorder Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. The temper outbursts are inconsistent with developmental level. The temper outbursts occur, on average, three or more times per week. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers). Criteria A D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A D. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these. The diagnosis should not be made for the first time before age 6 years or after age 18 years. By history or observation, the age at onset of Criteria A E is before 10 years. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. 39