Psychiatric illnesses in Children and Adolescents: types and treatment

1. Psychiatric illnesses in Children and Adolescents:types and treatment Lee W. Bradshaw APRN-BC McKay-Dee Behavioral Health Institute.

2. Types of illnesses: • Depression • Bipolar disorder • Anxiety disorders • ADHD

3. PHYSICAL Genetics: in the family Brain chemistry -autopsy studies -medications work Brain structure -hippocampus -trauma changes you PSYCHOLOGICAL Family problems are passed on Relationships Job School Legal Nature vs. Nurture(physical vs. psychological)

4. Depression • Major Depression has 5 of the 9 sx for at least two weeks • Dysthymia has 3 of 5 sx for more days than not, for two years (one year for kids), will not go for more than 2 months without having at least two sx • Depressive disorder NOS

5. Neuro-vegetative symptoms of depression • Concentration: impaired, decrease in functioning • Appetite and sleep: increased or decreased • Energy: decreased energy, tired, sluggish • Depressed mood: for most of the day every day (teens often display irritability vs. sadness) • Interest: loss of ability to enjoy pleasurable things • Isolation and withdrawal: • Guilt and worthlessness: excessive (5 minute) • Psychomotor agitation or retardation • Thoughts of death: may or may not include suicide

6. Treating Depression: Characteristics of anti-depressants • Improve symptoms of depression and anxiety • Not addictive, but not good to stop suddenly • May take weeks to fully work • Side effects usually mild, early and transitory • May cause agitation or suicidality, if bipolar • Usually safe in overdose: except MAOIs Wellbutrin/buprorion, or Effexor, Tricyclics

7. Types of Anti-depressants • SSRIs: • Prozac/fluoxetine • Paxil/paroxetine • Zoloft/sertraline • Celexa/citalopram or Lexapro/escitalopram • Luvox/fluvoxamine • SNRIs: • Effexor/venlafaxine • Cymbalta/duloxetine

8. Other Anti-depressants • Remeron/mirtazepine • Serzone/nefazodone • Wellbutrin/buproprion • Tricyclics, Tetracyclics and other old ones: • Elavil (amitriptyline) • Pamelor (nortriptyline) • Tofranil (imipramine) • Desyrel (trazodone) • Anafranil (clomipramine)

9. Bipolar Disorder • Bipolar I • Bipolar II • Cyclothymia • Different with children/adolescents, difficult to diagnose. More important to recognize what the diagnosis means in terms of treatment and management.

10. Bipolar I and II • Mania or hypomania: • Elevated, expansive or irritable mood for one week for mania, 4 days for hypomania • Includes three of the following (four if irritable) Pressured/excessive talking Less need for sleep Flight of ideas or thoughts racing Distractibility Increase in goal-directed activity Grandiosity Excessive interest in pleasurable activities: shopping, sex, drugs, investments, that have a high risk

11. Bipolar I vs. II • Mania with type I, may have depressive episodes, or mixed episodes: more likely to result in psychotic symptoms: paranoia, hallucinations, delusions, disorganized thinking • Hypomania alternating with depressive episodes with type II, less likely to be as severe: become psychotic

12. How are kids different? • No cadillacs and presidents • Hypersexuality • Grandiosity • More unstable with an anti-depressant? • Exacerbated by stimulants

13. Treating Bipolar Disorder • Lithium, Anti-epileptics, Atypical Antipsychotics • Stabilizing has priority • Is primary focus of treatment high or low • Anti-depressants may always cause instability • By nature more difficult to treat • More difficult to diagnose in younger patients

14. Lithium carbonate • Oldest: 1949 • Lowest suicide rate of all psychiatric meds • Anti-manic, mood stabilizer, helps agitation • As a salt, competes with sodium and wins: over hydration or dehydration causes toxicity • Change in renal function can change plasma levels: NSAIDS, diuretics, steroids • Narrow therapeutic window: 0.6-1.0, toxicity above 1.5, moderate 2-3, severe 3.0, multi-organ failure above 4.0 (dangerous in overdose) • Steady-state plasma levels in about 5 days, draw lab 10-12 hours after last dose (trough vs. peak)

15. Anti-epileptics • Depakote/divalproate sodium (valproic acid) • Indicated for seizures, headache, mania • Limited potential for liver toxicity • Weight gain, hair loss, GI distress • Therapeutic range: 50-125 • Tegretol/carbamazine • Seizures, mania • Greater potential for liver toxicity, small percentage have necrotic liver • GI distress, excess gum growth • Therapeutic range 4-12

16. More anti-epileptics • Topamax/topiramate and Neurontin/gabapentin • Adjunct anti-seizure • No liver metabolism, toxicity, drug interactions • Topamax is good for headaches, weight loss, but start slowly, rare acute angle glaucoma • Neurontin can help chronic neuropathic pain, help with anxiety and sleep, completely non-toxic: 8,000 mg/kg

17. Characteristics of anti-epileptics • Metabolized vs. excreted • Toxicity and liver failure possible, but unlikely • Can cause sedation, weight gain, GI upset • May cause depression • Anti-manic, mood stabilizer, decrease agitation • Watch for drug-drug interactions

18. Atypical Anti-psychotics • Seroquel/quietapine • Sedation, minimal dystonia, moderate wgt gain, fair anti-psychotic • Risperdal/risperidone • More dystonia, moderate wgt gain, prolactin, good anti-psychotic • Zyprexa/olanzapine • Little dystonia, sig. wgt gain, good anti-psychotic

19. Atypical Anti-psychotics • Abilify/aripipazole • Moderate dystonia, usually less wgt gain, good anti-psychotic • Geodon/ziprazodone • Sedation, moderate dystonia, very rare wgt gain, all or nothing: dose and effectiveness and tolerability • Invega/paliperidone • Similar to Risperdal, but usually less

20. Warnings about anti-psychotics • Metabolic syndrome: DM, lipids • Parkinsonian symptoms: EPS • Tardive Dyskinisia • Neuroleptic Malignant Syndrome

21. Attention Deficit Hyperactive Disorder • Lifelong, no “late onset”, noticed in kindergarten • Not ADD anymore • Predominately inattentive, hyperactive or combined • Paradoxical response to stimulants • Can have a mood or anxiety disorder also • Younger kids dx with ADHD, but don’t have it

22. Inattention • Forgetful • Loses things • Procrastinates (not defiant) • Easily distracted • Does not listen even when spoken to directly • avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) • difficulty organizing tasks and activities • fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities • Can’t sustain attention in tasks or play activities

23. Hyperactivity • Fidgets with hands or feet or squirms in seat • Can’t stay in seat • Runs about or climbs excessively • Can’t be quiet • "on the go" or often acts as if "driven by a motor" • talks excessively

24. Impulsivity • blurts out answers before questions have been completed • difficulty awaiting turn • interrupts or intrudes on others (eg, butts into conversations or games)

25. Other necessary conditions • symptoms that caused impairment were present before 7 years of age. • impairment from the symptoms is present in 2 or more settings • clinically significant impairment in social, academic, or occupational functioning

26. Treating ADHD • Stimulants: • Methyphenidates • Single vs dual isomers • Dextroamphetamines • single isomer • Pro-drugs • Multi-isomers, mixed salts • Stattera/atomoxatine • Wellbutrin/buproprion

27. Methyphenidate • Ritalin, Ritalin SR, Ritalin LA • Metadate • Concerta • Focalin • Daytrana (patch)

28. Dextroamphetamines • Dexedrine, spansules, dextrostat • Adderall (4 isomers) • Vyvanse

29. Other: • Strattera: • norepinephrine re-uptake inhibitor • may treat depressive symptoms also • longer acting: half-life, onset and attenuation • may be most agitating if Bipolar • Wellbutrin: • inhibits dopamine and norephinephrine re-uptake • no good data re: effectiveness • Very good at treating depression

30. Anxiety Disorders • PTSD (Post Traumatic Stress Disorder) • Has been exposed to a traumatic event where there was an actual or threatened death or serious injury • The person experienced a feeling of horror, helplessness or intense fear. • The event is re-experienced in one of the following ways • Recurrent and intrusive distressing recollections • Recurrent distressing dreams of the event • Acting or feeling as if the event were re-occurring • Intense stress when there are internal or external cues that symbolize or represent the event • Physical reaction when these cues occur.

31. Other Anxiety disorders • Panic disorder, an anxiety disorder with episodes of panic attacks: periods of intense fear that last 10 minutes, or longer, usually brief and very intense, with four of the following: • Palpitations and/or tachycardia • Sweating, trembling or shaking • SOB or a feeling of smothering, or of choking • Cx pain or discomfort, nausea or GI distress • Feeling of dizziness, faint or lightheadedness • Feeling of derealization • Fear of losing control or going crazy, or dying • Numbness or tingling, hot flashes or chills

32. Another Anxiety disorder • Acute Stress disorder: similar to PTSD, where there is a traumatic event with actual or threatened loss of life, with the sense of helplessness, horror or intense fear. • Instead of re-experiencing the event there are three of the following dissociative symptoms: • Feeling numb, detached, emotionally unresponsive • Reduction of awareness of surrounding, being “in a daze” • Derealization • Depersonalization • Dissociative amnesia • Lasts less than 30 days, if more than 30 = PTSD

33. Generalized Anxiety Disorder • 6 months of "excessive anxiety and worry" about a variety of events and situations. • significant difficulty controlling the anxiety and worry • clinically significant distress or problems functioning in daily life. • most days over the last six months of 3 or more (only 1 for children) of the following symptoms: 1. Feeling wound-up, tense, or restless2. Easily becoming fatigued or worn-out3. Concentration problems4. Irritability5. Significant tension in muscles6. Difficulty with sleep

34. Treating anxiety disorders • Treatment of choice: Anti-depressants, usually SSRIs • Benzodiazepines • Short-acting • Xanax/alprazolam • Ativan/lorazepam • Long-acting • Klonopin/clonazepam • Valium/diazepam • Non-addictive • Vistaril/hydroxyzine • Neurontin/gabapentin • Buspar/buspirone • Anti-hypertensives: Inderal/propanolol, Catapres/clonidine, Tenex/guanfacine

35. Characteristics of benzodiazepines • Benzodiazepines (xanax, ativan, valium, klonopin) are addictive • cannot stop suddenly if taken long enough • highly likely to be abused with persons with a hx of substance abuse • Fairly safe in overdose • Very effective, very quickly. • Provides more immediate relief • If not backed up by anti-depressants, will habituate, symptoms will return • Rebound anxiety