Management Of Depression And Anxiety

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1 Management Of Depression And Anxiety

2 CME Financial Disclosure Statement I, or an immediate family member including spouse/partner, have at present and/or have had within the last 12 months, or anticipate NO financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in context o the design, implementation, presentation, evaluation, etc of CME activities

3 Common Mental Health Issues Facing Children and Adolescents Introduction Objectives Anxiety Depression Medication treatments for Depression and Anxiety in youth Questions

4 Common Mental Health Issues Facing Children and Adolescents Objectives: Understand common mental health conditions affecting children and adolescents. Be able to screen and identify children/adolescents with certain psychiatric illnesses Become aware of the impact that psychiatric illnesses have on children and adolescents

5 Common Mental Health Issues Facing Children and Adolescents Anxiety Separation anxiety Specific phobias Social phobia Generalized Anxiety Disorder Panic Disorder Obsessive Compulsive Disorder Mood (Affective Disorders) Major Depressive Disorder Pediatric Bipolar Disorder Attention- Deficit/Hyperactivity- Disorder (ADHD) Disorders Oppositional Defiant Disorder Conduct Disorder Self-Injury Substance Use Psychosis Schizophrenia Eating Disorders Anorexia Nervosa Bulimia Disruptive Behavior

6 Anxiety Common Normal Fears Developmental Stage Feared Object or Situation 6-12 years Bodily Injury/sickness Burglars Being sent to principal Punishment Natural Disasters Failure/Rejection years Tests in school Low social competence Social evaluation Social embarrassment Psychological abnormality Mina K. Dulcan, MD, MaryBeth Lake, MD. Concise Guide To Child and Adolescent Psychiatry 4 th Edition. Arlington, VA: American Psychiatric Publishing, Inc., 2012

7 Anxiety Separation Anxiety Generalized Anxiety Disorder Social Anxiety Panic Disorder (with or without agoraphobia) Specific Phobias Post Traumatic Stress Disorder (PTSD) Obsessive Compulsive Disorder (OCD)

8 Anxiety Most common childhood psychiatric diagnoses 6-15% of school-aged children Girls:Boys, 2:1 (except for OCD and Social Anxiety DO) Child and Adolescent Psychiatry Certification Exam Prep Course; Anxiety Disorders Jennifer Kurth, BeatTheBoards.com

9 Anxiety Prevalence in each grade group Age Preschool Age 3-5 School Age Age 6-12 Adolescence Anxiety Separation Anxiety Disorder Specific Phobia Generalized Anxiety Disorder Selective mutism OCD Social Anxiety Disorder Panic Disorder Child and Adolescent Psychiatry Certification Exam Prep Course; Anxiety Disorders Jennifer Kurth, BeatTheBoards.com

10 Anxiety Anxiety: Social Phobia 2-5% youth Boys=girls Tends to start in adolescence Impaired social and academic/occupational functioning School avoidance Social withdrawal Substance use Difficulty with dating and intimacy Persists into adulthood Professional underachievement Depression Generalized anxiety symptoms Significant functional impairment Mina K. Dulcan, MD, MaryBeth Lake, MD. Concise Guide To Child and Adolescent Psychiatry 4 th Edition. Arlington, VA: American Psychiatric Publishing, Inc., 2012

11 Anxiety Generalized Anxiety Disorder 10 % or more of children and adolescents Girls:Boys, 2:1 Pervasive worries for at least 6 months Uncontrollable anxiety Associated with one of the following: Restlessness, feeling keyed up or on edge Easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbances Not due to any substance or medical condition Mina K. Dulcan, MD, MaryBeth Lake, MD. Concise Guide To Child and Adolescent Psychiatry 4 th Edition. Arlington, VA: American Psychiatric Publishing, Inc., 2012

12 Anxiety Panic Disorder Prevalence rates adolescents 0.6%-5% (rare in chidren) More common in females vs. males Recurrent unexpected panic attacks within 10 minutes Sweating Palpitations Trembling Shortness of breath Feeling of choking Chest pain Nausea Dizziness Fear of losing control or going crazy Fear of dying One of the attacks followed by one month of excessive worry about having attacks With or without agoraphobia 63% of adolescents report panic attacks Mina K. Dulcan, MD, MaryBeth Lake, MD. Concise Guide To Child and Adolescent Psychiatry 4 th Edition. Arlington, VA: American Psychiatric Publishing, Inc., 2012

13 Anxiety Obsessive Compulsive Disorder Prevalence in children and adolescents 1-4% Mild or transient rituals, obsessions, or compulsions are normal Ex. Rigid bedtime routines, collecting, arranging, storing objects, concerns about dirt and germs Chronic, waxing and waning course; many will reach full or partial remission Most Common Obsessions Contamination Pathological doubt Somatic thoughts Need for symmetry Most common compulsions Checking Washing Counting Confessing Mina K. Dulcan, MD, MaryBeth Lake, MD. Concise Guide To Child and Adolescent Psychiatry 4 th Edition. Arlington, VA: American Psychiatric Publishing, Inc., 2012

14 Anxiety Obsessive Compulsive Disorder Careful assessment of impairment Children and adolescents are often secretive about obsessions/compulsions Temper outbursts, academic struggles, eating changes may be initial concerns Cognitive Behavioral Therapy (CBT) is first-line treatment Mina K. Dulcan, MD, MaryBeth Lake, MD. Concise Guide To Child and Adolescent Psychiatry 4 th Edition. Arlington, VA: American Psychiatric Publishing, Inc., 2012

15 Mood (Affective Disorders) Major Depressive Disorder 2% in children 4%-8% in adolescents Male to female ratio 1:1 in childhood 1:2 in adolescents More than 70% of children and adolescents with depressive disorders or other serious mood disorders do not get diagnosed or treated (1) 1.) NIMH, Sept Birmaher et al Mina K. Dulcan, MD. Dulcan s Textbook of Child and Adolescent Psychiatry Arlington, VA: American Psychiatric Publishing, Inc., 2010

16 Mood (Affective Disorders) Major Depressive Disorder Suicide statistics 20% of teens seriously contemplate suicide 8% attempt suicide #2 cause of death ages #5 cause of death ages 5-14 cdc.gov

17 Mood (Affective Disorders) Major Depressive Disorder 2 weeks of persistent change in mood plus 5 or more symptoms depressed mood most of the day loss of interest or pleasure in all, or almost all, activities significant weight loss or weight gain too much or too little sleep fatigue or loss of energy trouble concentrating feeling worthless guilt about mood feeling restless or slowed down recurrent thoughts of wanting to die, suicidal ideation, suicide attempt Mina K. Dulcan, MD. Dulcan s Textbook of Child and Adolescent Psychiatry Arlington, VA: American Psychiatric Publishing, Inc., 2010

18 Mood (Affective Disorders) Major Depressive Disorder Presentation in children versus adolescents Children More irritable Low frustration tolerance Temper tantrums Physical complaints Social withdrawal Hallucinations School refusal Adolescents Verbalize feelings of depression More melancholic symptoms Anger Academic difficulties Behavior changes (ex. hostile, reckless) Frequent school absences Giving away valued possessions More suicide attempts Mina K. Dulcan, MD. Dulcan s Textbook of Child and Adolescent Psychiatry Arlington, VA: American Psychiatric Publishing, Inc., 2010

19 Mood (Affective Disorders) Major Depressive Disorder: Etiology and Risk Factors Single most predictive factor is a family history of depression Precipitated by stressors Losses Abuse Neglect Ongoing conflicts frustrations Mina K. Dulcan, MD. Dulcan s Textbook of Child and Adolescent Psychiatry Arlington, VA: American Psychiatric Publishing, Inc., 2010

20 Mood (Affective Disorders) Major Depressive Disorder: Co-morbidities 50-90% of depressed youth have other psychiatric disorders Most common Co-morbidities Anxiety Disruptive behavior disorders Attention deficit hyperactivity disorder (ADHD) Substance use disorder Child and Adolescent Psychiatry Certification Exam Prep Course; Anxiety Disorders Jennifer Kurth, BeatTheBoards.com

21 Mood (Affective Disorders) Major Depressive Disorder: Course and Prognosis Mean duration of a major depressive episode is 9 months Most will recover; 50% chance of another episode 70 % after 2 episodes 90 % after 3 episodes Serious and potentially fatal: 4-8% will commit suicide 20-40% will develop bipolar disorder Mina K. Dulcan, MD. Dulcan s Textbook of Child and Adolescent Psychiatry Arlington, VA: American Psychiatric Publishing, Inc., 2010

22 Mood (Affective Disorders) Major Depressive Disorder: Risk Factors for Suicidal Behavior History of prior attempts Substance abuse Disruptive behavior disorder Impulsivity Aggression Availability to lethal agents Exposure to negative events Family history and/or personal history of suicidal behavior Mina K. Dulcan, MD. Dulcan s Textbook of Child and Adolescent Psychiatry Arlington, VA: American Psychiatric Publishing, Inc., 2010 Child and Adolescent Psychiatry Certification Exam Prep Course; Anxiety Disorders Jennifer Kurth, BeatTheBoards.com

23 Psychopharmacological Treatments: Antidepressants Only 5 FDA approved antidepressants for children and teens Escitalopram (Lexapro): Depression; ages 12 and up Fluoxetine (Prozac): Depression; ages 8 and up OCD; ages 7 and up Fluvoxamine (Luvox) OCD: ages 8 and up Sertraline (Zoloft) OCD: ages 6 and up Clomipramine (Anafranil) OCD: ages 10 and up Mina K. Dulcan, MD. Dulcan s Textbook of Child and Adolescent Psychiatry Arlington, VA: American Psychiatric Publishing, Inc., 2010

24 /var/folders/tl/1ng148hj48d3183jdbmvm1d8 0000gn/T/com.apple.Preview/com.apple.Pr eview.pasteboarditems/child Depression Summary Algorithm (dragged).pdf

25 Psychopharmacological Treatments: Antidepressants SSRIs Are the first-line medication treatment for youth with MDD, OCD and other anxiety disorders Evidence stronger for benefit in anxiety vs depression Shorter half life in children, consider BID dosing Start low and go slow; careful monitoring Treat for at least 4 weeks, see weekly for first 4 weeks, then Bi-weekly If no response after 8 weeks, recommend alternative strategy 2004 Black box warning of suicidal thoughts and behaviors Anyone age 25 and under Mostly at initiation or at change of dose stage 4400 patients, 2% 2/100(control) versus 4% 4/100 (in RCTs) No actual completed suicides MDD: Major Depressive Disorder OCD: Obsessive Compulsive Disorder RCT:Randomized Control Trials Mina K. Dulcan, MD. Dulcan s Textbook of Child and Adolescent Psychiatry Arlington, VA: American Psychiatric Publishing, Inc., 2010

26 Psychopharmacological Treatments: Antidepressants SSRIs; Evidence-based Treatment Treatment for Adolescents with Depression Study (TADS) 2007 Fluoxetine + CBT (Cognitive Behavioral Therapy)> Fluoxetine or CBT alone Treatment of SSRI-resistant Depression for Adolescents (TORDIA) 2001 Non-responders to SSRIs may benefit from change to venlafaxine or another SSRI with or without CBT RCT:Randomized Control Trials Mina K. Dulcan, MD. Dulcan s Textbook of Child and Adolescent Psychiatry Arlington, VA: American Psychiatric Publishing, Inc., 2010

27 Generic Name SSRIs Brand Name Typical Daily Dose < 18 years Citalopram (L) Celexa mg Depression Escitalopram (L) Lexapro mg Depression Fluoxetine (L) Prozac 5-40 mg mg Mina K. Dulcan, MD, MaryBeth Lake, MD. Concise Guide To Child and Adolescent Psychiatry 4 th Edition. Arlington, VA: American Psychiatric Publishing, Inc., 2012 Indications supported by RCT <18 years Depression, social phobia, GAD OCD Fluvoxamine (L) Luvox mg OCD, social phobia, SAD, GAD Sertraline (L) Zoloft mg mg Bupropion TCAs Wellbutrin Wellbutrin SR mg ADHD Clomipramine (L) Anafranil mg OCD OCD GAD, Depression L: Comes also in liquid

28 Psychopharmacological Treatments: Antidepressants SSRIs; Risks and Side Effects Common: headaches, anorexia, weight loss, weight gain, bruxism, nausea, tremors, drowsiness, activation, and vivid or strange dreams Bipolar switching or manic reaction is less common but serious Carefully monitor for side effects especially in the beginning and at dose adjustments (Black box warning of increased suicidal thoughts/behaviors) Make sure to discuss possible sexual side effects (decreased libido, anorgasmia, and erectile dysfunction) especially with adolescents Fluvoxamine has lowest incidence of sexual side effects Possible withdrawal sx after sudden discontinuation: dizziness, headache, chills, tiredness, nausea, vomiting, diarrhea (slowly taper off) Less common with fluoxetine due to long half life More common with paroxetine and fluvoxamine Increased seizure risk with bupropion Mina K. Dulcan, MD, MaryBeth Lake, MD. Concise Guide To Child and Adolescent Psychiatry 4 th Edition. Arlington, VA: American Psychiatric Publishing, Inc., 2012

29 Common Mental Health Issues Facing Children and Adolescents

30 Common Mental Health Issues Facing Children and Adolescents

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