Wisconsin Alliance of Child Psychiatry and Pediatrics

1. Wisconsin Alliance of Child Psychiatry and Pediatrics Teleconference on Depression in Children and Adolescents October 12th 2010

2. Wisconsin Alliance of Child Psychiatry and Pediatrics Psychiatry Course Director: Joseph O’Grady Jr. M.D. FAAP Associate Professor of Clinical Psychiatry Medical College of Wisconsin Medical Director Phoenix Care Systems Inc 414-955-8935

3. WACPP teleconference Speakers on depression: Kambiz Pahlavan M.D. Medical Director Rogers Memorial Hospital 414-327-3000 Mark Siegel M.D. Aurora Psychiatric Hospital 414-454-6000

4. WACPP teleconference Outline Didactic presentation on depression Case studies review – principles of management Question and answer session

5. WACPP teleconference Teleconference as an educational activity not as a specific case consultation activity For a specific case consultation need, I would refer you to a child and adolescent psychiatrist for a clinical consultation

6. WACPP teleconference Educational goals for this presentation: Know and apply diagnostic criteria for depression Know and apply the indications for medication treatment of depression Know and apply indications for referral to a child and adolescent psychiatrist Know and apply the indications for hospitalization for depression Know and apply medication treatment options and monitoring for adverse medication effects

7. Introduction Depression in children and adolescents was misunderstood or poorly recognized and treated until the late 1970s and early 1980s. To some extent we still don’t fully appreciate this illness.

8. Depressed children were often labeled poor little sad thing, spoiled kid, mommy’s boy or girl, cry baby, kid who can’t be satisfied, bad parenting, etc. The misconception was worse with preschool children.

9. While we are in better shape today, still we are far from accuracy. Current criteria is predominantly adopted from adult psychiatry research and consensus. However, research in children and adolescents has brought more descriptive clarity to the adopted symptomatology from adult psychiatry.

10. Epidemiology of Major Depression in Children and Adolescents: Point prevalence in pre-pubertal children is 1-2% Point prevalence in adolescents is 3-8% Lifetime prevalence by the end of adolescence is about 20% PM Lewinsohn, et all 1998 EJ Castello, et all 2003 HZ Reinhertz, 1993

11. Gender distribution of Major Depression with the onset in puberty shows a 3:1 dominance by females probably due to: • Increase in estradiol and testosterone • Higher rate of anxiety and tendency for rumination in females • Increase in interpersonal conflicts in adolescents

12. Risk Factors: • Genetic • Cognitive distortions and negative view of the self, future, and the world • Family/Parental depression, criminality, substance abuse, lower education, lack of cohesion, and parent-child discord • Environmental factors like: neglect, maltreatment, physical and sexual abuse, association with devious peers…

13. Bereavement due to the loss of sibling, parents, friends and other significant people • Poor connectedness to the family, school, church, etc • Provocative challenge of noradrenergic and serotonergic neuro-transmitter shows differences between depression prone children and non depressed ones. • Neuroimmaging: reduce volume of left subgenual prefrontal cortex.

14. Steingard, et all showed decreased prefrontal cortex and increased third and fourth ventricular volume. McMillan reported increased pituitary and amygdala hippocompal ratio size Thomas et all showed decreased amygdala activation in depressed children

15. Diagnostic Criteria for Major Depression: • Five of the following nine symptoms should be present in the same two weeks, almost all day and nearly everyday. Symptom one and/or two has to be present. • Depressed mood by subjective reports or others observations. In children and adolescents it can be irritable mood instead of depressed. • Markedly diminished interest or pleasure in all or almost all activities.

16. Significant weight loss/gain without dieting and/or decreased/increased appetite. In children consider failure to make expected weight gains. • Insomnia/hypersomnia • Psychomotor agitation/retardation (observable by others, not only subjective feeling) • Fatigue or loss of energy • Worthlessness, excessive or inappropriate guilt • Diminished ability to think or concentrate, or indecisiveness • Recurrent thoughts of death, suicidal ideations with or without a plan, suicide attempt

17. B. Symptoms should cause significant distress or impairment in some important areas of life. C. Symptoms are not as a result of a medical condition (like hypothyroidism) or alcohol and drug abuse. D. Symptoms are not better accounted for by bereavement, unless is longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms or psychomotor retardation.

18. Indication for Referral to a Psychiatrist: • Diagnosis is not crystal clear because of co morbidities, severe parental confusion and dispute about their symptoms, severe parental discord, discrepancies between what you see and what parents and school report, etc • Initial course of 2-4 weeks of conservative medical treatment doesn’t cause an appreciable improvement. Placebo effect of any intervention is 40+%

19. Patient’s symptoms are getting worse in spite of adequate treatment. • Initial course of 2-3 months of psychotherapy hasn’t fostered appreciable stability. • Recurrence of the symptoms in spite of adequate treatment. • Numbers of people in the family are having serious psychopathology. • If you are not interested in treating children with affective instability. • Serious risk of suicide, homicide, and destruction of property

20. Indication for Hospitalization • Suicidality • Homicidality • Aggression which is hard to manage at home, school or on playground, and may risk the safety of the patient and others, and the property. • The patient who has been resistive to adequate treatment and continues to deteriorate.

21. Medication Treatment FDA approved medications for treatment of children and adolescents with major depression: Fluoxetine/prozac age 8-18 Escitalopram/lexapro ages 12-17 All others are ‘off-label’ although some have research evidence to support use sertraline/zoloft citalopram/celexa

22. Medication treatment High placebo response with antidepressants med response placebo res Fluoxetine 56% 35% Citalopram 47% 45% Escitalopram 64% 53% Sertraline 63% 53%

23. Medication treatment Treatment of Adolescents with Depression Study (TADS) Predictive of positive response: younger age less chronically depressed higher functioning less hopeless less suicidal ideation less melancholic symptoms fewer co-morbid disorders more expectation for improvement

24. Medication treatment Predictors of suicidal events: higher levels of suicidal ideation at baseline minimal improvement of depressive symptoms at least a moderate degree of depression acute interpersonal conflict

25. Medication treatment Box warning on antidepressants depression is associated with an increase in risk of suicide monitor appropriately and observe closely for clinical worsening, suicidal thinking, or unusual changes in behavior

26. Medication treatment Since FDA warnings, antidepressant use has declined by 10% overall, with decrease 40% by primary care providers Meta-analysis of 27 med treatment trials of major depression in pediatric population: number to treat: 10 number to harm 112

27. Medication treatment SSRI dosing: Fluoxetine 10-40 mg Escitalopram 10-20 mg Citalopram 10-60 mg Sertraline 25-150 mg

28. Mediation treatment Common side effects: nausea headache vomiting dizziness sedation decreased appetite dry mouth withdrawal effects: nausea, headaches, muscle aches, parathesias

29. Medication treatment Treatment progression: Start with SSRI if response continue for 1 year if no response, switch or augment Switch use different SSRI and cross taper doses use buproprion (Wellbutrin) use dual acting agent: venlafaxine (Effexor) or duloxetine (Cymbalta)

30. Medication treatment Augment with: buproprion (Wellbutrin) buspirone (Buspar) lithium thyroid aripiprazole (Abilify)

31. Summary slide Pediatric depression focus diagnostic criteria reviewed indications for medication treatment indications for child and adolescent psychiatrist referral indications for hospitalization medication treatment options medication adverse effects monitoring

32. Case reviews

33. Questions and answer session