13 th Pearl Leibovitch Clinical Day November 18th, 2014 Mounir H. Samy, MD, FRCP(C) Associate Professor of Psychiatry McGill University (ret.) FROM MEDICATION TO MINDFULNESS: NEW INSIGHTS INTO THE WORLD OF ANXIETY 1
None (No. I do not sell medication) DISCLOSURE 2
Developmental consideration Duration of the symptoms Severity of the symptoms (sense of suffering) Disability (impact on normal function/ life quality) THE «CASENESS» OR MAKING THE DIAGNOSIS 4
Separation anxiety School avoidance General Anxiety Disorder Panic Disorder Specific phobia Post-Traumatic Stress Disorder (PTSD) Obsessive Compulsive Disorder Acute Stress Disorder Anxiety Disorder NOS ANXIETY SPECTRUM DISORDERS 5
Selective mutism Adjustment disorder with Anxiety Sx Sleep Disorders Substance induced Anxiety Disorder AD due to medical illness Body Dysmorphic disorder Hypochondriasis Somatisation Disorder ANXIETY SPECTRUM DISORDERS 6
Hypoglycemia Hyperthyroidism Cardiac arrhythmias Migraines Pheochromocytoma Seizures Disorder Tourette s Iatrogenic MEDICAL CO-MORBIDITY 7
Additional AD Depression ADHD, Conduct Disorder Neuro-developmental conditions Autism Spectrum Disorder (Asperger) Psychosis Substance Use Disorder Tourette s Syndrome Eating Disorder PSYCHIATRIC CO-MORBIDITY 8
In child psychiatry, we treat a child s and/or his family s suffering and not a diagnosis. The treatment must always be multisystemic and multi-modal WHAT DO WE TREAT?
Psycho-education to the child and his family about his illness and its treatment (biblio-therapy, self help groups etc ) Individual Therapy Couple/Family Therapy Milieu Interventions (e.g. School) Medication TREATMENT: INCLUSIVE AND NOT EXCLUSIVE
Psycho-education of the Illness Anxiety Anxiety ME ME 11
Why medication, why this one, and how it works. Decide together. Define target symptoms. Temper unrealistic expectations. You stay in control, your personality doesn t change, you re not different from your peers How to use a PRN The build up period/ The therapeutic delay How long: time units/ 6-8 mo. 1 year The tapering down: 2-3 weeks Side effects of each phase Doesn't replace psychotherapy PSYCHO-EDUCATION ABOUT THE MEDICATION WHAT TO SAY TO THE ADOLESCENT AND HIS FAMILY? 12
13
Age, co-morbidity, life style, cultural factors Type of AD and therapeutic objective Hx of medication in the child and the family Associated symptoms e.g. depression, somatic symptoms, sleep Ability to swallow pills Previous trials Taking other medications, alcohol, illicit drugs GUIDELINES: CHOICE OF MEDICATION 14
The family is the psychological unit: Patterns of Parental Ambivalence Guilty Angry Disaffected Fusional Excessive fear of the damage that will be caused by medication on the child. Accusatory of care takers and institutions He does not need medication. He behaves this way on purpose and should be able to control himself Mechanical compliance. Often forgets. Not sure what the medication is supposed to do. Does not see a difference whenever the child takes it or not There is nothing wrong with the child. Wants to be left alone. Threatened by external influence. Blames prob. on alienated family members or on the ext. environment (school, social services) 15
Anxiolytics (Bensodiazepine):Lorazepam (Ativan), Clonazepam (Rivotril), Alprazolam (Xanax) Atypical Anxiolytic : Buspiron (BuSpar) SSRI s: Fluoxetine (Prozac), Sertraline (Zoloft), Escitalopram(Cipralex), paroxetine (Paxil), Trazodone (Desyrel) Beta Blockers: Propranolol (Inderal) Psychotropics: Risperidone (Risperidal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Aripiprazole (Abilify) CLASSES OF MEDICATION IN AD 16
SSRIs: Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Fluvoxamine (Luvox) Citalopram (Celexa) Escitalopram (Cipralex) CURRENT ANTIDEPRESSANTS 17
SNRIs: Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Others: Bupropion (Wellbutrin Zyban) Trazodone (Desyrel) Mirtazapine (Remeron) Duloxetine (Cymbalta) MORE RECENT ANTIDEPRESSANTS 18
Serotonine Reuptake Inhibition: mood, sex, sleep, appetite, GI, sweating NE Reuptake Inhibition, tremors, agitation, spasms Antihistaminic: somnolence, drowsiness Antiadrenergic (anti alpha 1): dizziness Anticholinergic (peripheral and CNS):dry mouth, blurred vision, constipation, urinary retention Withdrawal effects: 7-14 days, dizziness, flu like Sx. POSSIBLE SIDE EFFECTS OF ANTIDEPRESSANTS 19
Weak evidence links SSRIs to suicidal behavior in youth. No significant increase in suicidal behavior in clinical trials of youth. Evidence supports benefits of SSRIs in reducing suicide. Alternatives not effective or readily available. (Executive summary of the American College of Neuropsychopharmacology. January 21 st, 2004) SSRI S AND SUICIDAL BEHAVIOR IN YOUTH 20
Over-prescription, under-prescription, inadequate prescription and hasty prescription Abuse, misuse, diversion, random compliance, poor FU False beleifs, mistrust and poor communication Side effects (under-reported or exaggerated), drug interactions, co-morbidities, dependence Expedite, mechanical with the occultation of the inner world of the child and all psychodynamic factors Passivity (but eye glasses don t do the reading). PROBLEMS WITH MEDICATION
Remission for Separation Anxiety Less remission for Panic Disorders 30% will develop another Psych. Dis., half of them another AD ±50% life time risk of AD AD in Adolescents increases by twofold risk of AD in adulthood secondary complications: risk of SUD, on selfesteem, on relational and occupational life COURSE AND OUTCOME OF AD 22
A good medical practice informs on all available treatment, is multimodal and accounts for the inner world of the child as well as family and cultural issues To be successful, a medication trial requires no less amount of love and empathy than any other treatment modality and a bit more trust. CONCLUSION I
In this world when it comes to treatment It is better to be born as late as possible CONCLUSION II 24
MERCI THANK YOU