An Overview of Anxiety and Mood Disorders in Youth Mary Kay Nixon MD FRCPC Clinical Associate Professor, UBC Affliliate Associate Professor, UVic Family Physicians Conference February 22, 2012 Victoria, BC
Anxiety Disorders Separation Anxiety Disorder Social Anxiety Disorder Specific phobias Obsessive compulsive li disorderd Panic disorder with agoraphobia without agoraphobia
Anxiety Disorders Generalized anxiety disorder Posttraumatic stress disorder Acute stress disorder Anxiety disorder due to a general medical condition Substance induced anxiety disorder Anxiety disorder d not otherwise specified
Epidemiology Children and adolescents withanxiety disorders are more likely to develop Mood Disorders, eg Major Depression Substance abuse Other anxiety disorders Other sequelae include Social, family and academic impairment
Biological Risk Factors Genetics Parental anxiety disorder Temperament Behavioral inhibition
Environmental Risk Factors Anxious parents Model fear and anxiety, reinforce anxious coping behaviours, maintain avoidance Overprotective, overcontrolling, overly critical parents Limit development of autonomy and mastery
Treatment Psychoeducation Psychotherapy CBT Family work/family therapy when indicated Pharmacological Therapy when indicated
Cognitive Behaviour Therapy Dealing with cognitive distortions Jumping to conclusions Mind Reading Overgeneralizing Catastrophizing Black and White thinking Personalizing Emotional reasoning
FDA approval Fluoxetine: FDA approved, effective for OCD; Major Depression to age 7 Fluvoxamine: FDA approved to age 8 OCD Sertraline: FDA approved to age 6 OCD Citalopram: no controlled trials in youth Escitaloprma:FDA approved to age 12 for MDD Clomipramine: FDA approved to age 10 OCD Only used for extreme treatment resistant OCD
Assessment Tools Resources SCARED (Screen for Child Anxiety Related Disorders) For ages 9 18 Parent and child versions For GAD, Sep Anx, SAD and signifant school avoidance Childrens Yale BrownObsessive Compulsive Scale Childrens Yale Brown Obsessive Compulsive Scale Lists obsessions, compulsives and rates severity of both
Resources Patient Self Help Taming the Worry Dragons, by Garland & Clark Keys to Parenting your Anxious Child, by K. Manassis On line Resources Anxiety BC website (just google Anxiety BC ) Under parenting for childhood anxiety info Under self help tools How to Chill For teen girls with anxiety/stress Mindyourmind.ca
Mood Disorders Depressive Disorders Major Depressive Disorder (MDD) Dysthymic Disorder Adjustment Disorder with Depressed Mood Bipolar Disorders Bipolar I, II Cyclothymic Disorder Bipolar NOS Mood Disorder due to a General Medical Condition or Substance Induced
MDD Diagnosis Classic signs may exist in youth Either depressed mood or decreased interests t 5/9 symptoms lasting >2 weeks SIGECAPS (sleep, interests, guilt, energy, concentration, appetite,psychomotor retardation, suicidal ideation) Watch for irritability
Medications Fluoxetine is considered first line Important to start low and go slow 10 mg po x 1 wk, then 20mg po od Very long half life Side effects Nausea, headaches, impaired sleep, vivid dreams, decreased appetite, decreased libido Akathisia, behavioural activation
Bipolar Disorder Bipolar I Disorder Manic episode Plus or minus Depressive Episode Bipolar II Disorder Hypomanic episode At least one major depressive episode Bipolar Disorder NOS
Epidemiology 1% of adult population 0.6 1% in children and adolescents 15 20% illness started before 20 years old usually presents first with depressive episode and premorbid bdanxiety
Hypomanic Episode Briefer if duration (at least 4 days or ultra rapid cycling) The episode is not severe enough to cause marked impairment in social or occupational functioning does not necessitate hospitalization does not have psychotic features The disturbance in mood and the change in functioning i are observable bl by others The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic
Bipolar disorder Depressive episode: Factors that can predict the development of bipolar disorder rapid onset of episode psychotic symptoms psychomotor retardation family history of bipolar illness hypomanic or manic symptoms with antidepressants
Summary MDD Treatment plans can include Individual Therapy (CBT, IPT, Supportive) Family Therapy School interventions Mdi Medications Medication alone is rarely appropriate
Summary Children and adolescents taking SSRIs should be monitored closely Especially early in the course of treatment When doses are being altered When switching medications Consider fluoxetine as first line
Summary 30 40% of children and youth with depression will not respond to initial medication So may need to switch to a different SSRI Not everyone needs medication Milder cases respond well to psychotherapy p py py Psychotherapy may enhance the effectiveness of medication
Summary Need to consider the consequences of not treating depression in children and adolescents Ongoing problems with friends, school Substance abuse, eating disorders 40% will go on to a second episode within 2 years Over half will eventually attempt suicide Estimated that depression increases the risk of a first suicide attempt by at least 14 fold
Resources Assessment Tools: Child Depression Inventory Beck Youth Inventory (age 13 and up)
Resources Guidelines for Adolescent Depression in Primary Care (GLAD PC) www.glad pc.org Antidepressants t Skills for Teens www.mcf.gov.bc.ca/mental_health/pdf/dwd_writable.pdf www.bcchildrens.ca/psychmeds www.nami.org www.teenmentalhealth.org www.bpkids.org www.insync group.ca ( re self injury)